CIHM 
Microfiche 


(IMonograplis) 


ICIVIH 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microraproductions  /  Institut  Canadian  da  microraproductions  historiquas 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


0 
D 

D 

n 

n 

□ 
n 

D 
D 

n 


Coloured  covers  / 
Couverture  de  couleur 

Covers  damaged  / 
Couverture  endommag^ 

Covers  restored  and/or  laminated  / 
Couverture  restaurde  et/ou  pellicul^e 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material  / 
Reli^  avec  d'autres  documents 

Only  edition  available  / 
Seule  Edition  disponible 

Ti'-ht  binding  may  cause  shadows  or  distortion  along 
interior  margin  /  La  reliure  serr§e  peut  causer  de 
I'ombre  ou  de  la  distorsion  le  long  de  la  marge 
intdrieure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  Use  peut  que  certaines  pages 
blanches  ajout^es  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  6tait 
possible,  ces  pages  n'ont  pas  6\6  fiimies. 


□    Additional  comments  / 
Commentaires  suppl^mentaires: 


L'Institut  a  microfilm^  le  meilleur  exemplaire  qu'il  lui  a 
6\6  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-6tre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modifk:ation  dans  la  m^tho- 
de  normale  de  filmage  sont  indiqu^s  ci-dessous. 

I     ]   Coloured  pages  /  Pages  de  couleur 

I I   Pages  damaged  /  Pages  endommagdes 


n 


Pages  restored  and/or  laminated  / 
Pages  restaur^s  et/ou  pellicul^es 


r~p^  Pages  discoloured,  stained  or  foxed  / 
LJ— J   Pages  dteolor^es,  tachet^es  ou  piqu^es 

I   Pages  detached  /  Pages  d6tach6es 

|y/|   Showthrough  /  Transparence 

I      I   Quality  of  print  varies  / 


0 


D 


Quality  in^gale  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  materiel  suppl^mentaire 

Pages  wholly  or  partially  obscured  by  errata  slips, 
tissues,  etc.,  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  ^t^  filmdes  k  nouveau  de  fagon  k 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
film^es  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


This  item  it  f iimed  at  the  reduction  ratio  checked  below  / 

C«  document  est  film^  au  taux  de  reduction  indiqu^  ci-dessous. 


lOx 

14x 

18x 

/• 

22x 

26x 

30x 

y 

12x 


16x 


20x 


24x 


28x 


32x 


Th«  copy  filmed  h«r«  has  b««n  raproduetd  thanks 
to  tha  ganarosity  of: 

University  of  British  Columbia  Library 
Vancouver 


L'axamplaira  filmA  fut  raproduit  grica  A  la 
gin^rosit*  da: 

University  of  British  Columbia  Library 
Vancouver 


Tha  imagas  appearing  hara  ara  tha  bast  quality 
possibia  considaring  tha  condition  and  lagibility 
of  tha  original  copy  and  in  kaaping  with  tha 
filming  contract  spacificationa. 


Original  copias  in  printed  paper  covers  ere  filmed 
beginning  with  the  front  cover  »nii  ending  on 
the  last  psge  with  e  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  eppropriate.  All 
other  originel  copies  ere  filmed  beginning  on  the 
first  psge  with  e  printed  or  illustrated  imprea- 
sion,  and  ending  on  the  lest  page  with  a  printed 
or  illuatrated  impreasion. 


The  iaat  recorded  freme  on  eech  microfiche 
shell  contain  the  symbol  -^  (meening  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Mops,  plates,  cherts,  etc..  mey  be  filmed  st 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  sxposure  are  filmed 
beginning  in  the  upper  left  hend  corner,  left  to 
right  and  top  to  bonom.  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  images  suivantas  ont  «t«  raproduites  avec  la 
plus  grand  soin,  compta  tanu  da  la  condition  at 
da  la  nattet*  da  I'axempieire  film*,  at  an 
conformit*  avec  les  conditions  du  contrat  da 
filmege. 

Lea  axempleires  originsux  dont  la  couvartura  en 
pepier  eet  imprimie  sent  filmis  en  commanpant 
per  le  premier  plat  at  an  terminent  soit  par  la 
derni*re  page  qui  comporte  une  emprainta 
d'imprassion  ou  d'illustration,  soit  par  la  second 
plat,  salon  le  cas.  Tous  les  sutres  axamplstras 
origineux  sent  filmis  en  commenpant  par  la 
premiere  pege  qui  comporte  une  empreinte 
d'impreasion  ou  d'illustration  at  en  termlnant  par 
la  darnlAre  pege  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  appareitra  sur  la 
darniire  image  de  cheque  microfiche,  salon  le 
cas:  le  symbols  -i^  signifie  "A  SUIVRE".  le 
symbols  ▼  signifie  "FIN". 

Les  csrtes.  plenches.  tableeux.  etc..  pauvant  dtre 
filmte  A  des  taux  de  reduction  diff grants. 
Lorsque  le  document  est  trop  grand  pour  itra 
reproduit  en  un  seul  clich*.  il  est  film*  *  partir 
de  I'angle  supirieur  gauche,  de  gauche  i  droite. 
at  de  haut  en  bea.  en  prenent  le  nombre 
d'images  n*cessaire.  Les  diegrammes  suivants 
illustrant  le  m*thode. 


1  2  3 


1 

2 

3 

4 

5 

6 

MICROCOTY   RiSOlUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No.  2) 


1.0 


I.I 


1.25 


12.8 

■  02 

■  40 


2.5 
2.2 

2.0 
1.8 


A  APPUE.U  IM/IGE    Inc 

Sr  1653   East   Morn   Street 

B'JS  Rocliesler.   Ne«   York         14609       USA 

^S  (716)  482  -  0300  -  Phone 

^S  (716)   288  -  5989  -  Fax 


Tube  re  u  I  um 
S  J  perus 


A  PRACTICAL  GUIDE 

f  xamini^ioii^^  the  Ear 


BY 


•V 


I 


C  V, 


»«?■■■  ^■.  '■  «^.  ^  •,  ?^ 


raj 


JBk 


A  PRACTICAL  GUIDE 


TO  THE 


Examination  of  the  Ear 


BY 

SELDEN  SPENCER,  A.B.,  M.D. 

Instructor  of  Otology  in  Washington  University;  Aural  Surgeon 

to  the  Martha  Parsons  Free  Hospital 

for  Children. 


With  an  Introductory  Chapter 

BY 

H.  N.  SPENCER,  M.  D.,  LL.  D. 

Professor  of  Otology  in  Washington  Univers     . 


C.  V.  MOSBY 

Medical  Book  and  PubUihing  Company 

St.  Lomn 

1908 


Copyrighted  1908,  by 
C.  V.  MOSBY  MEDICAL  BOOK  &  PUB.  CO. 


Nixon-Jones  Printing  Company 
St.  tiouis,  Mo. 


Z\%% 


NOTE. 

My  thanks  are  due  to  my  father  for  the  introductory 
chapter,  to  my  clinical  professor,  Dr.  D.  C.  Gamble,  for  his 
kind  approval  of  this  publication,  and  to  my  colleague,  Dr. 
Eugene  Senseney,  for  the  suggestion  that  there  was  a  neces- 
sity for  such  a  treatise. 

Dr.  Eugene  Senseney  and  Dr.  W.  Mills  have  rendered 
valuable  service  in  making  drawings. 


2723  Washington  Ave., 

St.  Louis. 


CONTENTS. 

PAGE 

Preface '^ 

Introduction ^ 

Chapter       I.     Method  of  Procedure  (General  Con- 
sideration)         15 

Chapter      II.    The  External  Ear 17 

Chapter    III.     Diseases  of  the  Canal 20 

Chapter     IV.    The  Middle  Ear 23 

Chapter      V.    The  Middle  Ear  Continued,  Non  Sup- 
purative Conditions   ....        26 
Chapter     VI.    The  Middle  Ear  Continued,  Post  Sup- 
purative Conditions        ...        29 
Chapter  VII.    The  Middle  Ear  Continued,  Suppura- 
tive  Conditions 31 

Chapter  VIII.    The  Middle   Ear  Continued,   Acute 

Purulent  Otitis  Media    ...        33 
Chapter    IX.    The  Middle  Ear  Continued,  Chronic 

Purulent  Otitis  Media    ...        35 
Chapter      X.    The  Middle  Ear  Continued,  Opera- 
tions in  Chronic  Purulent  Oti- 
tis Media 38 

Chapter    XI.    The  Internal  Ear 40 

Chapter  XII.    Hearing  Tests 42 

Chapter  XIII.    Intra-Cranial   Complications    ...        45 
Chapter  XIV.    Exercises  in  the   Surgical   Anatomy 

of   the  Temporal    Bone    .    .        47 

(5) 


1 

III 


1 


PREFACE. 

This  little  book  is  offered  as  an  aid  to  students  in  attend- 
ance upon  the  undergraduate  course  in  otolgy.  The  hope 
is  also  entertained  that  it  may  be  fou.id  useful  to  many 
physicians  who,  from  lack  of  opportunity,  have  not  acquired 
the  experience  and  skill  necessary  to  conduct  an  examina- 
tion of  the  ear.  It  is  not  designed  as  a  work  on  the  anatomy 
so  much  as  a  method  of  study  and  the  means  by  which  a 
familiarity  with  pathological  conditions  of  the  ear  may  be 
acquired. 

Diagnosis  is  the  fundamental  part  of  any  branch;  and 
essential  to  a  diagnosis  in  otology  is  the  ability  to  make 
an  intelligent  inspection  of  the  drumhead,  of  the  tym- 
panic cavity  and  of  the  otitic  region,  as  well  as  the  nasal  cavi- 
ties and  the  pharynx.  No  one  should  attempt  ea^'  work 
without  this  ability;  and  to  the  end  of  aiding  students  and 
physicians  in  acquiring  such  ability  this  work  is  undertaken. 

(7) 


Ito 


INTRODUCTION. 

bpecialism  in  modicine  goes  back  to  the  beginning  of 
medical  history.  It  was  the  practice  of  the  Greeks  and  of 
the  Egjrptians,  and  at  no  time  has  it  interfered  with  the 
unity  of  medicine,  but  on  the  other  hand  we  are  able  to  trace 
to  it  whp+ever  advancement  has  been  most  substantial  and 
most  enduring.  The  benefit  of  a  part  has  redounded  to  the 
interest  of  tho  whole.  It  must  over  be  in  the  interest  of 
progress  that  this  division  of  labor  should  be  maintained. 
There  was  true  wisdom  in  the  Hippocratic  oath  that  surgery 
should  be  set  apart  and  allowed  only  to  those  who  make  it  a 
business.  There  was  equal  wisdom  in  the  contention  of 
John  Hunter  that  surgery  and  medicine  cannot  be  divorced. 
Just  as  the  practice  of  medicine  and  surgery  have  been  con- 
ducted with  the  full  knowledge  of  their  interdependence  so  the 
growth  of  specialism  has  been  fostered  and  quickened  by  a 
knowledge  of  the  interrelation  of  all  the  organs  of  the  body. 
So  great  has  been  the  advance  of  knowledge  in  scientific 
medicine  and  scientific  surgery — the  institution  of  t-uch 
diverse  methods,  required  in  different  regions,  and  the  con- 
trol of  variable  technics — that  a  distribution  of  labor  is  more 
necessary  today  than  ever  before.  The  advance  which  has 
been  made  in  otology  quite  equals  that  which  has  been 
wrought  in  other  departments.  In  the  progress  of  inves- 
tigation and  clinical  study  it  came  to  be  known  that  the 
ear  could  not  be  considered  as  an  independent  organ. 
The  evidence  of  ear  disease,  it  was  soon  found,  was  often 
manifested  by  symptoms  which  appeared  in  other  and 
remote  regions  of  the  body.  Cough,  spasm  of  the  glottis, 
aphonia  and  asthma,  in  instances,  were  relieved  by  treat- 
ment of  the  ear.  Faintness  instead  of  being  regarded 
necessaiily  as  a  cardiac  lesion  per  se,  it  was  discovered, 

(9) 


10 


INTRODUCTION. 


might  be   a   reflex  irritation   due  to  an  aural  lesion,  and 
so    of    nausea    and   vomiting.      Vertigo,    visual    disturb- 
ances and  headache,  all  were  found  to  be  common  in  associa- 
tion with  disorders  of  the  ear.     Brain  complications,  as  ab- 
scess of  the  brain,  meningitis,  phlebitis,  sinus  thrombosis, 
epilepsy  and  facial  paralysis,  were  referred  to  the  ear  by 
clinical   experience   and   post   mortem   examination.    The 
rich  supply  of  nerves  to  the  external  and  middle  ear  and  the 
free  anostomoses  of  these  nerves  when  traced  out  served  to 
solve  many  and  perplexing  questions.     Through  the  trige- 
minal and  pneumogastric  nerves,  branches  of  which  supply 
the  external  and  middle  ear,  the  stomach,  lungs  or  diaphragm 
may  suffer  from  reflex  irritation  induced  by  so  simple  a 
thing  as  the  presence  of  a  foreign  body  in  the  meatus,  or 
lesions  in  the    xternal  auditory  canal  or  tympanic  cavity. 
On  the  other  hand  it  came  to  be  known  that  most  diseases 
of  the  ear  were  the  result  of  infection,  directly  or  indirectly, 
the  consequence  of  disease  processes  in  other  organs  of  the 
body  or  in  the  system.     It  is  important  for  the  student  to 
learn  and  for  the  general  practitioner  to  remember  that  the 
great  majority  of  ear  diseases  have  their  incipiency  in  in- 
fancy and  early  childhood.     Many  of  mem  are  closely  con- 
nected with  such  general  diseases  as  the  acute  exanthemata. 
It  is  of  the  utmost  importance  to  bear  this  in  mind  for  the 
ear  complication  is  liable  to  be  overlooked,  at  the  moment 
of  crucial  importance  for  the  preservation  of  the  hearing, 
by  the   medical   attendant   whose  resources   are  severely 
taxed    in    combating   the   systemic    trouble.     During  the 
course  of  any  of  the  acute  febrile  or  infectious  diseases  fre- 
quent and  thorough  inspection  should  be  made  of  the  ear 
even  though  there  may  be  no  aural  symptoms  complained 
of.    The  rhinitis  of  scarlet  fever  and  measles  especially  pre- 
d;  pose  to  ear  trouble  of  virulent  form.     In  pneumonia  and 


INTRODUCTION. 


11 


bronchitis  a  middle  ear  trouble  may  result  from  the  passage 
of  the  infectious  germ  through  the  blood  current  to  the  mid- 
dle ear  or  by  the  condensation  of  air  in  the  tympanic  cavity. 
Lesions  of  the  ear  are  as  common  as  lesions  of  the  eye  with 
kidney  troubles.  In  Bright's  disease  a  change  in  the  ten- 
sion of  the  labyrinth  may  be  brought  about  by  interference 
with  the  general  venous  circulation.  Diabetic  patients  are 
commonly  affectec'  with  eczema  of  the  auricle  or  furuncu- 
losis  of  the  external  auditory  canal.  It  would  be  tedious, 
as  it  is  unnecessary,  to  continue  this  recital  so  as  to  include 
all  the  diseases  in  which  an  ear  complication  might  arise.  It 
is  too  well  known  to  necessitate  a  mention  of  the  fact  that 
the  syphilitic,  rheumatic,  tubercular  and  strumous  cachex- 
iae  predispose  to  and  unfavorably  influence  diseases  of  the 
ear.  I  have  desired  mainly  to  impress  the  undergraduate 
students  with  the  necessity  for  the  place  which  is  given  to 
this  branch  in  the  university  curriculum. 

To  refer  to  the  scope  of  otology  and  the  many  interest- 
ing problems  which  are  engaging  the  minds  of  aurists  today 
would  be  manifestly  out  of  place  in  an  introduction  to  this 
small  volume  which  deals  only  with  the  first  lessons. 

The  introductory  study  of  otology  contemplated  in  the 
undergraduate  course  of  the  university  is  well  outlined  in 
the  pages  of  this  little  brochure.  With  the  extensive  cur- 
riculum necessary  in  the  teaching  of  modern  medicine  it 
will  be  readily  understood  that  more  than  this  could  not  be 
undertaken  even  if  more  might  be  deemed  desirable.  The 
extent  of  the  instruction  in  this  branch  is  limited,  and 
considering  the  difficulty  of  grasping  a  subject  so  intricate 
and  so  concealed,  owing  to  the  anatomical  pecuUarities  of 
the  part,  the  student,  I  am  sure,  will  welcome  the  effort  that 
is  here  made  to  assist  him.  The  laboratory  training  has 
long  seemed  to  me  to  require  some  such  elucidation  as  this. 


12 


INTRODUCTION. 


,il|' 


It  is  not  intended  to  supplant  but  to  supplement  what  is 
to  be  found  in  many  admirable  text  books  on  diseases  of 
the  ear.    Permit  me    to  repeat:    The  necessity  for  some 
knowledge  of  the  diseases  of  the  ear  and  an  understanding 
of  their  relation  to  other  disease  conditions  is  too  well  un- 
derstood at  the  present  time  to  require  contention  or  argu- 
ment on  the  part  of  those  who  have  made  special  research 
and  have  had  peculiar  experience  in  this  department  of 
physiological  and  cHnical  medicine.    The  reflex  phenomena 
have  become  better  understood  and  the  more  immediate 
relation  of  the  ear  to  the  respiratory  and  nerve  center  func- 
tions emphasize  the  importance  of  this  study  and  demon- 
strate its  necessity  to  an  intelligent  practice  of  medicine. 
The  difficulty  of  obtaining  a  clinical  picture  has  been  one  of 
the  chief  hindrances  in  the  way  of  studying  the  evidences  of 
otic  influence  in  disease.    This  can  be  overcome  only  through 
patience.    By  manipulation  and  observation  the  necessary 
skill  will  be  gradually  acquired,  and  a  recognition  of  this 
fact  is  the  best  protection  against  the  likelihood  of  venture- 
some interference.    The  limitations  of  the  general  prac- 
titioner will  be  comprehended  and  the  better  in'    med  will 
be  more  ready  to  call  into  requisition  tho  services  of  an  ac- 
credited specialist. 

The  local  and  general  therapeutics  of  the  ear,  the  surgery 
of  the  ear  and  the  physics  of  the  ear  may  be  considered  as 
beyond  the  scope  ox  this  little  volume  and  as  belonging  more 
properly  to  the  post  graduation  study  of  this  branch.  The 
contributions  of  comparatively  recint  surgery  to  our  for- 
mer knowledge  and  the  great  possibilities  of  cure  for  many 
diseases  of  the  ear  which  we  were  in  the  habit  of  considering 
incura.  e,  have  done  much  to  exalt  this  branch  in  the  con- 
fidence of  the  profession  and  has  served  to  place  otology  in 
the  front  rank  of  recognized  specialties. 


GENERAL  DIRECTIONS  FOR  STUDENTS. 

Each  student  will  be  required  to  make  his  own  diagnosis 
and  will  be  graded  on  his  work.  Of  course,  due  allowance 
will  be  made  in  the  beginning  for  lack  of  experience.  The 
only  instrument  which  the  beginner  should  use  without  the 
permission  of  the  instructor  is  the  speculum.  Where  any 
obstruction  is  to  be  removed  from  the  external  auditory 
meatus  the  assistants  must  first  be  consulted,  and  with  their 
permission  the  students  may  use  such  means  as  these  advise. 
Not  even  the  speculum  should  be  used  until  the  history  of 
the  affection  has  been  obtained  and  the  external  portion 
of  the  ear  inspected.  A  strict  observance  of  this  rule  will 
often  save  the  physician  from  embarrassing  experiences  and 
the  patient  from  needless  pain. 

In  addition  to  diagnosis  and  ordinary  treatment,  an  op- 
portunity will  be  given  students  to  witness  such  surgical 
procedures  as  will  arise  during  the  term. 

The  student  should  familiarize  himself  with  the  appear- 
ance of  the  normal  drumhead,  and  the  use  of  the  head 
mirroi  and  speculum,  by  supplementing  his  reading  with 
practice  on  his  fellow  students. 


(13) 


INSTRUMENTS. 


ii!* 


1. 

2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 


The  following  instruments  will  be  found  in  each  alcove 
for  the  use  of  the  students  in  this  course: 

A  set  of  three-ear  specula,  Wilde's. 

Nasal  speculum. 

Cotton  applicator. 

Sexton's  double  blunt  ring  curette. 

A  set  of  three  eustachian  catheters. 

Auscultation  tube. 

PoHtzer  bag. 

Ear  probe. 

Nasal  wash  apparatus  (Spencer). 

10.  Spray  apparatus  (Devilbis). 

11.  Post  nasal  mirror. 

12.  Cotton  box  (Phillips'). 

In  addition  to  the  above,  all  solutions  used  in  the  clinic 
will  be  found  on  the  tables.  Each  alcove  i^  furnished  with 
a  strong  artificial  Ught,  the  McKenzie  condensor  being  used 
in  conjunction  with  the  Wellsbach  mantle.  The  student 
must  furnish  his  own  head  mirror.  All  other  necessary 
instruments  for  major  or  minor  surgical  work,  for  exami- 
nations, or  for  whatever  purpose  will,  when  needed,  be  fur- 
mshed  the  student  by  one  of  the  assistants.  The  clinic 
room  is  thoroughly  equipped. 


(14) 


CHAPTER   I. 


METHOD  OF  PROCEDURE  (GENERAL  CONSIDERATIONS). 

A  brief  hisU*.  is  essential;  an  elaborate  one  is  unneces- 
sary. We  are  to  learn  principally  what  can  be  obtained 
from  objective  symptoms.  Do  not  place  too  much  reliance 
on  the  patient's  account.  The  first  question  should  refer 
to  the  present  trouble.  What  has  led  the  patient  to  seek 
the  advice  of  a  physician?  How  long  has  the  affection 
been  in  existence?  What  was  its  apparent  cause?  If  these 
questions  do  not  btin^  out  a  definite  description  the  pa- 
tient must  be  questioned  as  to  pain,  noises,  deafness,  and 
any  sensation  varying  from  the  normal.  If  pain  is  present 
we  should  ascertain  its  location;  its  character,  constant  or 
intermittent;  its  duration  and  its  severity.  At  this  time  it 
is  neither  practicable  nor  necessary  to  discuss  the  various 
causes  of  tinnitus  aurium.  The  student  should  be  aware 
that  many  causes  exist  extraneous  to  the  ear,  and  he 
should  only  endeavor  to  find  out  if  the  ear  itself  is  affected. 
In  cases  where  deafness  or  tinnitus  is  present  the  duration, 
character  and  apparent  cause  should  be  ascertained  and 
the  hearing  tost  made.  If  the  patient  complains  of  some 
peculiar  sersatiun  only,  a  definite  description  of  this  sen- 
sation 8ho.-ld  be  obtained.  In  some  cases  it  may  be  well 
to  inquire  a.s  to  former  treatment,  family  history,  occu- 
pation and  previous  health. 

When  a  student  has  obtained  by  interrogation  what  he 
deems  sufficient  information,  he  should  proceed  with  the 
physical  examination.     Make  it    an  invariable   rule,  both 

(16) 


16 


EXAMINATION    OF  THE    EAR. 


here  and  in  your  after  life,  always  to  examine  both  ears. 
Do  not  begin  your  examination  by  the  introduction  of  an 
aural  speculum,  particularly  if  pain  be  a  symptom.  First 
of  all  an  inspection  of  the  external  ear  and  the  canal  must 
be  made.  If  the  canal  wall  is  not  swollen  or  tender,  the 
speculum  should  be  gently  introduced  and  the  inspection 
extended  to  the  entire  canal  and  tympanic  membrane,  or, 
if  this  is  lacking,  the  labyrinth  wall.  It  may  be  necessary 
to  extend  still  further  this  inspection  so  as  to  include  the 
parts  in  the  vicinity  of  the  ear.  Enlarged  glands  must  be 
noted;  nor  should  redness  or  swelling  be  overlooked.  Pal- 
pation should  be  made,  and  any  tenderness  on  pressure, 
especially  over  the  mastoid  tip,  should  be  observed.  Fi- 
nally, the  nasal  cavities,  pharynx,  fauces  and  teeth  should 
be  examined. 

This  general  examination  may  be  augmented  with  the 
use  of  such  instruments  as  the  probe  and  the  auscultation 
tube,  to  be  used  at  the  discretion  of  the  assistant.  A  de- 
scription of  these  will  be  found  in  this  syllabus. 


.1      ! 


.ill' 


rs. 
an 

■8t 
iSt 

be 
3n 
>r, 
ry 
he 
be 
il- 

■e, 
'i- 
Id 

le 
>n 
e- 


M 


K- 


mk  mt^wmMt,r^tiimmSii«d  to 

i^4m^m  inliiitef  ilililarge, 

|hei»  b  lo  (Iw^ge.     This, 

W&L  oectit  in  this  region 

"   BO 


WJwiiHf! 


vv'tl!      ^    -i^B0WFHmr^9|K^iHHFrV^^.     It 

ilHWii»wHWIt^.  Fo^ahondrii 
o  be    pnmmyihe  aai 
nudbkWi  li  the 


,3s;^ 


•e    ear  will 


It       t 


.  I  ■ 

f  • 

'    i 

i 


CHAPTER  II. 
THE  EXTERNAL  EAR. 

The  Auricle.— The  auricle  is  not  often  the  seat  of  dis- 
ease but  it  should  be  examined  for  such  as  may  occur.  It 
is  occasionally  affected  with  an  eczema,  either  limited  to 
itself  or  associated  with  a  similar  condition  in  the  external 
auditory  canal.  This  may  be  due  to  an  irritating  discharge, 
or  it  may  be  present  where  there  is  no  discharge.  This, 
-^ith  other  affections  of  the  skin,  will  occur  in  this  region 
and  will  need  attention,  but  the  points  on  diagnosis  of 
these  conditions  will  be  obtained  in  the  skin  clinic  and  so 
need  not  now  occupy  our  time.  Haematoma  is  of  espe- 
cial interest  to  the  otologist,  but  is  of  rare  occurrence.  It 
is  readily  recognized  by  a  swelling,  either  tense  and  filled 
with  fluid  or  very  irregular  in  appearance.  Perichondritis 
is  so  allied  to  this  condition  as  to  be  practically  the  same 
thing.  New  growths  and  malformations  of  the  auricle 
must  be  sought  for  and  recognized. 

The  Peri  otic  Region.— Glands  in  the  neighborhood  of 
the  ear  may  be  enlarged.  This  is  usually  secondary  and 
the  trouble  should  be  traced  to  its  source.  Periostitis  and 
abscess  in  the  post-auricular  region  will  cause  swelling  and 
marked  tenderness.  Later  on  the  process  will  show  fluc- 
tuation. This  trouble  simulates  mastoiditis,  but  the  gen- 
eral symptoms  in  the  latter  case  are  usually  much  mo' 
severe.  The  condition  of  the  middle  ear  will  aid  us  .a 
differentiating,  but  an  exploratory  operation  is  at  times 
necessary.    Where  mastoid  swelling  extends  into  the  neck 

2 

(17) 


18 


EXAMINATION  OF  THE   EAR. 


it  usually  indicates  that  some  of  th'  products  of  inflamma- 
tion have  escaped  through  an  opening  in  the  mastoid  proc- 
ess. Such  an  opening  may  be  congenital,  or  due  to  the 
disease.  This  is  called  Bezold's  symptom.  Any  sinus  in 
the  post-  auricular  region  must  be  carefully  noted.  The 
probe  must  be  used  t-  feel  for  dead  or  exposed  bone;  for 
a  sinus  in  this  locality,  associated  with  destruction  in  the 
tympanic  cavity,  calls  for  radical  procedures;  no  half-way 
measures  will  suffice. 


.  a 


jf 


The  Canal. — Inspection  is  begun  without  the  speculum, 
the  ear  being  gently  pulled  upward  and  backward  to 
straighten  the  canal.  Marked  swelling  and  redness  of  the 
canal  walls,  an  unusual  tenderness  or  some  readily  recog- 
nized condition,  as,  for  example,  a  protruding  polyp  may 
lead  us  to  eliminate  the  use  of  the  speculum  altogether. 
Where  any  such  condition  is  present,  it  must  be  recognized 
and  stated  before  proceeding  further.  If  no  such  condition 
is  present,  the  speculum  should  be  introduced  and  the  in- 
spection carried  out  to  cover  the  entire  visible  portion  of 
the  canal  and  drumhead.  What  was  said  of  skin  affections 
of  the  auricle  will  apply  to  the  canal,  but  there  are  some 
peculiar  local  conditions  that  must  receive  due  con- 
sideration. 

Conditions  which  are  not  really  pathological  may  annoy 
us  and  hinder  our  examination;  such,  for  example,  as  an 
excessive  growth  of  the  vibrissae  (the  small  hairs  of  the 
canal),  soft  wax,  which  piles  in  front  of  the  speculum  (if  it 
is  introduced  before  the  canal  has  been  wip^d  out),  or  a 
narrow  or  tortuous  canal  may  make  it  difficult  to  see  but  a 
small  portion  of  the  drumhead.  Before  dealing  with  the 
pathological  conditions  of  the  canal  we  must  consider  the 


THE  EXTERNAL  EAR. 


19 


subject  of  foreign  bodies.  All  sorts  of  objects  are  reported 
as  having  been  found  in  the  external  auditory  meatus,  and 
we  must  continually  bear  in  mind  the  possibility  of  the 
presence  of  a  foreign  body,  though  these  cases  are  by  no 
means  frequent.  Examination  by  inspection  is  of  the 
greatest  importance  in  these  cases.  Too  much  reliance 
must  not  be  placed  on  the  history  given  by  the  patient,  for 
it  frequently  leads  us  to  believe  some  foreign  body  present 
when  the  examination  discloses  a  very  different  trouble. 
Our  inspection  may  have  to  be  augmented  by  the  gentle 
use  of  the  probe  to  determine  the  character  of  the  object 
and  the  best  means  for  its  removal.  The  kinds  of  bodies 
and  the  methods  of  removal  need  not  be  dwelt  on;  a 
warning  as  to  the  possible  presence  either  with  or  without 
such  history  is  all  that  is  necessary  here,  but  the  necessity 
for  a  careful  examination  must  not  be  forgotten. 


CHAPTER  III. 


'ji  III' 


DISEASES  OF  THE  CANAL. 

Impacted  Cerumen.— Of  the  pathological  conditions  in 
this  locality  impacted  cerumen  is  perhaps  the  commonest. 
The  diagnosis  is  not  difficult.     The  cerumen    is  seen  as  a 
brown    mass,  and  the  use   of  the  blunt  ring   curette  will 
confirm  our  diagnosis  and   give  us  valuable  information  as 
to  the  consistency  of  the  mass,  which  may  vary  from  a  soft 
paste  to  a  dense  hardness.     Sometimes  a  small  quantity  of 
cerumen,  the  size  of  a  garden  pea,  will  lie  close  to  the  en- 
trance and  fill  the  lumen,  giving  the  appearance  of  a  canal 
entirely  filled  with  cerumen.     Epidermal  flakes  mixed  with 
cerumen  may  simulate  the  appearance  of  impacted  cerumen; 
and  this  may  be  small  in  quantity  and  easily  removed,  or 
it  may  block  the  entire  canal.     Still    another  condition,  at 
timc3  similar  in  appearance  but  far  more  difficult  of    re- 
moval, is    what  is    termed  keratosis   ohdurans.    This    has 
been  described  as  a  "laminated  epidermal   plug,  consisting 
of   desquamated  cells  arranged   in  layers  concentrically." 
The  student  should  differentiate  between  these  conditions 
by  gentle  and  proper  use  of  the  blunt  ling  under  the  guid- 
ance of  the  assistant.     A  small  quantity  of  cerumen  lying 
near  the  orifice  will  be  easily  removed  by  the  curette;  if  the 
canal  is  filled  with  cerumen  we  can   learn  in  a  moment  by 
such  use  of  the  ring,  whether  it  is  soft   or  hard  of  consist- 
ency, and  whether  we  should  at  once  resort  to  the  syringe 
or  not.    If  the  mass  be  keratosis   obdurans   we  will  dis- 
(20) 


DISEASES  OF  THE   CANAL. 


21 


cover  the  scales   and  the   white  appearance  underneath 
the  covering  of  cerumen  and  will  recognize  its  denseness. 

Diffuse  External  Otitis. — Before  turning  our  atten- 
tion to  the  diseases  of  the  middle  ear,  there  remains  a 
word  to  be  said  concerning  the  various  forms  of  external 
otitis.  The  presence  of  a  diffuse  inflammation  in  the  ex- 
ternal auditory  meatus  must  be  recognized  and  classified. 
There  are  several  types  of  such  inflammation.  For  ex- 
ample, there  may  be  simply  a  diffuse  redness  and  swelling 
of  the  skin;  an  exudate  with  this;  a  tendency  toward 
granulation;  or  a  desquamative  process.  If  a  diffuse  ex- 
ternal otitis  is  associated  with  a  suppurative  condition  of 
the  middle  ear,  it  is  in  all  probability  secondary  to  it.  If, 
however,  we  can  eUminate  a  middle  ear  affection  by  the 
appearance  of  the  drumhead,  or  by  proving  that  no  per- 
foration is  present  and  that  the  hearing  is  good,  we  can  be 
sure  that  the  disease  is  limited  to  the  external  ear,  and 
that  the  secretion  is  an  exudate  from  the  inflamed  skin. 
But  it  is  no  easy  matter  to  determine  whether  such  a  dis- 
ease is  acute  or  chronic. 

A  form  or  a  complication  of  diffuse  external  otitis  is  the 
parasitic  affection  known  as  otomycosis,  due  to  the  asper- 
gillus.  There  are  several  varieties  named  in  Latin  terms, 
according  to  the  color;  for  example,  niger,  flavus  and  so 
forth.  By  the  fuzzy,  powdery  appearance,  the  diagnosis 
may  usually  be  readily  made;  and  this  may  be  confirmed 
by  the  microscope. 

Circumscribed  External  Otitis. — Furunculosis  is  of  fair- 
ly common  occurrence  and  is  not  diflScult  to  recognize.  In 
these  cases  the  pain  is  severe,  and  such  a  history  will 
lead  us  at  once  to  be  on  the  outlook  for  this  condition.   On 


22 


EXAMINATION  OF  THE   EAR. 


raising  the  auricle  gently-and  this  will  be  pai.iful-and 
looking  without  a  speculum  into  the  canal,  it  will  be 
found  swollen  and  often  occluded  by  the  swelling.  Gentle 
pressure  over  the  tragus  will  show  the  sensitiveness  of  this 
region.  If  it  is  necessary  to  differentiate  this  from  a  mid- 
die  ear  affection  the  hearing  test  may  be  of  some  value; 
but  It  sometimes  happens  that  the  middle  ear  is  intact, 
a  though  the  canal  is  much  swollen  and  the  hearing  greatly 
affected.  There  is  usually  little  difficulty  in  making  this 
differentiation. 

What  has  been  said  concerning  ordinary  skin  diseases,  as 
these  relate  to  the  auricle,  applies  in  a  large  measure  to  the 
ci-.ial. 

Exostosis.— This  is  of  comparatively  rare  occurrence. 
Ihe  bony  growth  is  an  osteoma,  and  may  be  either  diffuse 
or  pedunculated,  and  may  obstruct  the  canal  to  a  more  or 
less  extent.  Suppurative  otitis  media  may,  or  may  not  be 
present. 


'^•'ll 


I    ■  I 


■*'  ^'k : 


mAFFm  TV. 


-»..i 1.. 


It 

I  'ii 


chapti:k  jy. 

THE  MID  )Ln  EAR. 

The  canal  having  been  inspected,  tne  car  drum  next  calls 
for  our  attention.  The  student  must  always  be  able  to  tell 
whether  or  not  he  sees  the  tympanic  membrane,  and  if  not 
why  not.  Is  the  view  obstructed?  If  so,  in  what  way?  If 
the  view  is  not  obstructed,  and  the  ordinary  landmarks  of 
the  drum  membrane  cannot  be  seen,  the  student  must 
again  question  himself  as  to  the  reason.  Is  the  drumhead 
Itself  partly  or  wholly  destroyed?  Or  is  it  so  distorted  by 
mflammatory  conditions  that  one  is  unable  to  recognize 
these  landmarks?  If  the  drumhead  is  present,  we  must  be 
able  and  ready  to  say  how  we  know  that  it  is  present.  We 
must  describe  its  appearance  and  be  able  to  name  those 
pomts  which  I  have  referred  to  as  "landmarks." 

Normal  DRUMHEAD.~The  drumhead  is  oval  in  shape  and 
IS  set  obliquely,  the  upper  and  posterior  portion  being 
nearer  to  the  eye  of  the  examiner  than  the  anterior  and  in- 
ferior portions.  The  following  landmarks  must  be  looked 
for  and  noted:  The  short  process  of  the  hammer,  which  is 
found  in  the  upper  anterior  portion;  leading  downward  and 
backward  from  this,  terminating  in  the  middle  point,  which 
18  called  the  umbo,  is  the  handle  of  the  hammer  (or  mal- 
leus); leading  downward  and  forward  from  this  is  the  so- 
called  triangular  light  spot,  or  cone  of  light.  From  the 
short  process  folds  run  forward  and  backward.  These  are 
the  anterior  and  posterior  folds.    That  portion  of  the  drum 

(23) 


lr;if; 


on 


24 


EXAMINATION  OP  THE  BAR. 


It 


n 


•«i 


Jli 


above  the  folds  is  called  SchrapnelPs  membrane,  or  the 
membrana  flaccida,  and  the  portion  below  is  called  the 
membrana  vibrans.  The  color  of  the  membrane  is  a  pearl 
grey.  In  locating  the  landmarks  just  cited,  make  it  a  point 
to  look  first  for  the  short  process  of  the  malleus,  as  it  is  the 
most  constant,  and  all  the  other  points  can  be  traced  in 
order  from  it. 

Abnormal  Conditions.— Before  taking  up  the  different 
diseases  that  may  occur  in  the  middle  ear,  it  will  be  well  to 
consider  in  a  general  way  how  the  appearance  of  th(i  drum 
membrane  and  the  visible  parts  of  the  tympanic  cavity  may 
vary  from  the  normal.     These  diflferences  must  be  noted 
and  their  significance  stated.    What  has  caused  these  con- 
ditions, and  what  bearing  they  have  on  the  diagnosis  will  be 
more  fully  di-cussed  when  considering  the  different  diseases 
of  the  middle  ear.    Where  no  destruction  of  tissue  has  oc- 
curred, the  commonest  variation  from  the  normal  appear- 
ance will  be  in  the  color  and  luster  of  the  membrane.    It 
may  be  whiter  and  lusteriess  and  have  the  appearance  of 
being  thickened,  or  it  may  be  darker  in  color  and  almost 
as  transparent  as  glass.    More   often  in  acute  cases,  but 
even  in  chronic  cases,  it  may  be  red  from  congestion  and 
inflammation.    White,   chalky  spots    are  often   seen,  and 
scars  of  old  perforations  must  not  be  overiooked.    In  addi- 
tion to  these  discolorations  of  the  membrane,  we  can  find  dis- 
tortions and  absence  of  the  landmarks;  where  there  has  been 
no  destruction  of  tissue,  we  often  find  the  landmarks  invis- 
ible on  account  of  swelling  and  congestion  of  the  membrane, 
or  we  find  certain  features  accentuated,  as  when  the  short 
process  is  particularly  prominent  in  cases  where  there  is  a 
markeu  retraction  (or  drawing  in)  of  the  drumhead.    In 


THE  MIDDLE  EAR. 


25 


these  cases  the  light  spot  is  most  often  wanting  or  inter- 
rupted, and  the  handle  of  the  malleus  is  foreshortened.  The 
'olds  running  from  the  short  p'ocess  are  also  prominent  in 
these  cases.  Where  there  has  bt-jn  destruction  of  tissue  we 
may  find  almost  any  amount  of  loss  from  a  small  perfor- 
ation to  an  entire  absence  of  the  drum  membrane,  and  even 
the  ossicles  and  bony  wall. 

General   Classification. — In  giving   a  diagnosis  of  a 
middle  ear  condition,  the  examiner  must  first  of  all  say  to 
which  of  the  following  three  main  classes  it  belongs:  suppu- 
rative,  non-suppurative  or  post-suppurative,  and,  further, 
whether  it  is  acute  or  chronic.     A  suppurative  otitis  media 
is  an  inflammation  where  pus  is  present  in  the  middle  ear, 
and  can  be  recognized  by  the  presence  of  a  perforation. 
Before  the  membrane  has  perforated,  it  will  be  sufficient  to 
diagnose  acute  conditions,  simply  as  acute  otitis  media,  and 
as  in  the  purulent  form  a  paracentisis  will  be  indicated,  the 
diagnosis  will   not  be  lon<!5  in  doubt.    A  nonnsuppurative 
case  is  one  where  no  pus  is  present,  either  in  the  middle  ear 
or  in  the  canal  from  the  middle  ear,  and  where  the  drum- 
head is  intact.    A  postnsuppurative  case  is  one  where  there 
are  visible  evidences  of  destruction  of  tissue  due  to  a  suppu- 
rative process.    If  a  patient  gives  a  definite  history  of  pre- 
vious suppuration,  but  no  visible  evidences  of  it  are  pres- 
ent the  condition  should  not  be  called  a  post-suppurative 
one. 


,1 


CHAPTER  V. 

THE  MIDDLE  EAR    CONTINUED— NON-SUPPURATIVE 

CONDITIONS. 

Acute  Non-Suppurative  Otitis  Media.— In  acute    af- 
fections of  the  middle  ear  where  there  has  been  no  perfora- 
tion, the  cardinal  signs  of  inflammation  will  be  present  to  a 
more  or  less  degree.     In  the  earliest  stage  the  disease  may 
be  limited  to  the  eustachian  tub-  indeed,  a  tubal   catarrh 
or  a  eustachian  salpyngitis  may  be  a  disease  per  se.   The  di- 
agnosis in  this  stage  is  rather  diflficult,  for  the  symptoms  are 
not  well  marked.    Deafness  will  be  slight  and  pain  will  not 
be   severe.     The  appearance   of   the    drumhead    may   be 
slightly  changed.    There  will  be  some  retraction  which  will 
be  recognized  as  dcscbribed  above,  but  it  will  be  much  less 
marked  than  in  the  chronic  form  of  middle  ear  catarrh.   The 
redness  in  these  cases  is  limited  to  the  line  of  the  handle  of 
the  hammer  and  Schrapnell's  membrane.     However,  such  a 
hyperemia  is  so  often  produced  by  the  manipulation,  unless 
the  examination  is  very  carefully  carried  out,  that  we  must 
be  sure  to  eliminate  this  cause  before  attaching  to  it  any 
significance.     When  the  inflammation  has  extended  to  the 
middle  ear  all  of  the  symptoms  will  be  more  marked.    The 
membrane  may  be  congested  and  severe   pain  and   impair- 
ment of  hearing  may  be  associated  with  it.     Where  there  is 
bulging   of    the   drum    membrane   associated    with   deaf- 
ness, pain   and  redness,    there   is  fluid  in   the  middle  ear 
cavity;  but  it  is  not   possible  to  state  positively   whether 
(26) 


THE  MIDDLE  EAR — NON-SUPPURATIVE  CONDITIONS.      27 

this  fluid  is  of  a  purulent  nature  or  not,  so  that  a  diagnosis 
of  acute  otitis  media  is  sufficient.  Where  severe  pain  and 
bulging  are  present  a  paracentisis  is  imperative,  and  it  is  ad- 
visable wherever  bulging  is  at  all  marked.  Pus  may  or  may 
not  be  found.  Milder  measures  may  be  used  where  the 
redness,  swelling  and  pain  are  less  severe. 

Serous  Effusion  In  Tympanic  Cavity.— Another  of  the 
acute  conditions  found  without  perforation  is  effusion  of  a 
mucous  or  serous  exudate  into  the  middle  ear.  The  diag- 
nosis in  such  cases  is  comparatively  easy.  When  the  effu- 
sion is  not  so  profuse  as  to  cause  bulging,  or  to  fill  the 
entire  cavity,  the  line  of  the  fluid  will  be  plainly  visible; 
this  line  will  remain  horizontal,  and  so  its  relation  to  the 
landmarks  of  the  drum  membrane  will  change  as  the  pa- 
tient tilts  the  head  backward  or  forward.  Inflation  by  the 
Politzer  method  or  the  catheter  dispels  this  line  and  a 
foamy  or  bubbly  appearance  is  the  result.  On  auscultating 
with  the  rubber  tube  during  inflation  the  characteristic 
bubbling  sound  unmistakably  informs  us  of  the  presence  of 
fluid.  The  subjective  symptoms  associated  with  this  condi- 
tion are  impairment  of  hearing,  noises  and  a  disagreeable 
full  feeling  in  the  ear.     Pain  is  not  usually  a  symptom. 

Chronic  Non-Suppurative  Otitis  Media.— Subjective 
symptoms  here  vary  in  all  degrees  of  deafness,  with  tinnitis 
aurium  or  peculiar  sensations  in  the  ear.  The  appearance 
of  the  drum  membrane  is  of  importance  in  all  pathological 
conditions  of  the  middle  ear,  but  in  this  class  of  cases  its 
significance  must  not  be  overestimated.  It  must  be  remem- 
bered that  persons  with  practically  normal  hearing  may 
show  changes  in  the  appearance  of  the  drum,  and  we  must 
consider  the  subjective   symptoms  of  more  import  in  this 


28 


EXAMINATION   OF  THE   EAR. 


class  of  cases  than  in  others.  The  hearing  tests  will,  of 
course,  be  of  greatest  importance.  Where  the  subjective 
symptoms  above  referred  to  are  associated  with  a  drum 
membrane  which  is  markedly  retracted  with  thickening  or 
atrophy  of  the  membrane,  a  diagnosis  of  chronic  catarrhal 
otitis  media  may  be  made.  Where  the  appearance  of  the 
drum  membrane  is  practically  normal,  and  the  subjective 
symptoms  are  as  above  stated,  our  diagnosis  will  be  oto- 
sclerosis, provided  the  eustachian  tube  and  the  naso-pharynx 
are  normal. 

Where  there  is  a  markedly  thickened  membrane  a  diag- 
nosis of  hyperplasia  may  be  made.  Let  us  recapitulate  the 
kinds  of  chronic  non-suppurative  otitis  media  and  our  mode 
of  diagnosis. 

Otitis  Media  Catarrhalis  Chronica. — Retraction  marked, 
thickening  or  thinning  of  the  membrane,  deafness,  tinnitus 
may  or  may  not  be  present,  and  in  association  with  these 
symptoms  of  a  middle  ear  condition  we  find  pathological 
changes  in  the  nose  or  naso-pharynx,  and  more  or  less  ob- 
struction of  the  eustachian  tube. 

Hyperplasia. — Thickening,  some  retraction,  tubal  obstruc- 
tion not  marked. 

Otosclerosis. — More  nearly  normal  appearance  of  drum 
membrane  and  naso-pharynx;  subjective  symptoms  the 
principal  basis  of  diagnosis. 

Without  going  too  deeply  into  this  subject  I  will  mention 
the  value  of  auscultation  by  means  of  the  eustachian  cath- 
eter and  the  tube.  The  auscultation  sounds  are  difficult  to 
describe  and  familiarity  with  them  is  only  obtained  by 
practice.  The  effect  of  catheterization  on  hearing  should  be 
noted,  and  it  should  influence  our  prognosis. 

Siegel's  otoscope  will  also  aid       '•^  making  our  diagnosis. 


':j 


Wi 


(tiwiiiifiiiii 

k  wm^t^  ir  -Mm  omiim 


■^^^^  ^W^V  IHi^H 


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f  miHp,  Hi  Mil  place 
^mv^mtkter,  and  if 


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190111 


I  «  :,    • 

tit;; 
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v?» 

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"■*'.j.  , 


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/ 


CHAPTER  VI. 

THE  MIDDLE  EAR  CONTINUED-POST^UPPURATIVE 

CONDITIONS. 

POST-SUPPURATIVB   CONDITIONS   OP  THE    MiDDLE   EaR.— 

A  po8t-8uppurative  condition  is  recognized  by  scars  on  the 
membrane,   or  absence  of  a  part  or  all  of  the  membrane. 
The  membrane  may  have  been  almost  totally  destroyed  and 
a  new  membrane  may  have  been  formed;  indeed,  the  mem- 
brane may  be  entirely  gone  and  the  ossicles   also  lacking. 
Of  course,  where  such  a  condition  is  the  result  of  operative 
procedures  we  can  only  learn  of  that  from  the  patient,  and 
we  cannot  be  positive  even  from  the   history  whether  the 
operation  was  performed  in  a  suppurative  or  non-euppura- 
tive  case.    Histories  are  not  always  reUable.    In  such  cases 
the  landmarks  of  the  drum  membrane  will  be  lacking,  and 
those  of  the  labyrinth  wall  will   be  in  evidence.    Where 
the  ossicles  are  still  present  the  scar  may  be  of  almost  any 
size.    It  is  usually   easy   to  recognize  it  as  such  after  a 
little  practice,  but  if  we  are  in  doubt  as  to  whether  a  spot  is 
still  an  unclosed  perforation  or  a  scar,  we  can  readily  recog- 
nize which  it  is  by  inflation  and  auscultation.  If,  however,  the 
auscultation    sound  should  leave  us  in  some  doubt,  even 
though  we  are  sure  that  we  have  located  the  tube  and  are  get- 
ting air  through  it  into  the  middle  ear  cavity,  we  can  place 
the  free  end  of  the  auscultation  tube  in  a  glass  of  water,  and  if 
a  perforation  be  present  air  bubbles  will  rise  in  the  water  as 
we  inflate.    Siegel'b  otoscope  will  also  be  of  value  in  mak- 

(29) 


30 


EXAMINATION  OF  THE   EAR. 


J; 


ing  our  diagnosis.  Before  taking  up  the  suj  irative  condi- 
tions of  the  middle  ear,  a  word  should  be  paid  about  the 
appearance  of  the  inner  wall  of  the  tympanum,  as  seen 
when  the  drum  membrane  and  the  two  larger  ossicles  are 
lacking.  If  coveretl  with  epithelium  the  color  may  simu- 
late that  of  the  drum  membrane,  but  when  an  active  sup- 
purative process  is  present  the  color  is  usually  a  vivid  red. 
The  anterior  and  central  portion  of  what  we  now  see  is  a 
convex  surface,  which  is  called  the  promontory.  Above 
and  posteriorily  may  be  seen  the  long  process  of  the  incus 
articulating  with  the  head  of  the  stapes,  which  bone  is  in- 
serted in  the  oval  window.  The  chorda  tympani  nerve 
which  passes  over  this  process  of  the  incus,  is  sometimes  seen 
through  transparent  drum  membranes,  but  where  there  is 
enough  destruction  of  tissue  to  bring  its  position  into  view, 
it  is  itself  destroyed.  Behind  the  promontory  below  is  seen 
the  niche  of  the  round  window.  Even  though  the  drum 
membrane  be  completely  removed,  these  landmarks  may  be 
obscured  by  granulation  tissue  or  the  swollen  and  hyper- 
emic  condition  of  the  wall. 


••HI. 


If 


SKi 


CHAPTER  VII. 

THE  MIDDLE  EAR  CONTINUED— SUPPURATIVE 
CONDITIONS. 

General  Classification  of  Suppurative  Otitis  Media  — 
In  considering  suppurative  conditions  of  the  middle  ear  we 
must   divide  these   affections   primarily    into:  first,   acute 
cases;   second,   chronic  ca^es.     This  classification   is,  how- 
ever, an  arbitrary  one,  and  the  d\  Acting  lines  are  not  well 
defined;  it  must  not  be  forgotten  that  there  may  he  a<  v^ 
exascerbations  of    chronic   cases.    In  making  a  diagnosu.. 
then,  the  first  thing  to  be  said  is  whether,  in  so  far  as  we 
can  tell,  we  are  dealing  with  an  acute  or  a  chronic  condi- 
tion.   But  when  we  have  made  this  statement  we  have  only 
begun,  and  such  a  diagnosis  will  not  be  accepted  as  final 
Suppuration  is  not  a  disease  of  itself  but  the  result  of  a  dis- 
ease.   The  presence  of  pus  in  the  ear  i.s  only  a  symptom. 
This  IS  notably  true  of  chronic  cases.     In  acute  cases  where 
there  is  nothing  more  than  a  suppurating  mucous  mem- 
brane present,  the  disease  of  the  mucous  membrane  may  be 
Idiopathic.     In   classifying,    then,    as  to  acute  or  chronic 
oases    If  we  take  duration  as   a  guide,  we  may  approxi- 
niately  place  six  weeks  as  the  dividing   line,  and  say  that 
those  cases  of  longer  standing  than  this  are  chronic,  and 
those  of  SIX  weeks  or  less  are  acute.    But  such  a  classifica- 
tion IS  of  very  little  practical  worth,  and  the  best   rule  for 
determimng  whether  a  case  is  acute  or  chronic,  is  to  call  all 
cases  chrome  in  which  the  perforation  is  large  enough  to  be 

(31) 


32 


EXAMINATION  OF  THE  EAR. 


\!1 

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..4 

11:: 
I" 

't  > 

.  i 


ir: 
1. 1. 

tiJ.I 


gaping  and  plainly  visible.  Even  this  rule  is  not  constant, 
as  often  a  great  destruction  of  tissue  may  take  '  lace  in  very 
virulent  cases  of  only  a  few  days'  standing,  ^  in  scarlet 
fever,  for  example.  On  the  other  hand,  a  ca&v  may  have 
existed  for  the  period  of  a  year  or  more  with  small  destruc- 
tion of  tissue,  particularly  in  cases  where  there  is  some  ob- 
struction of  the  eustachian  tube.  In  these  cases,  however, 
the  perforation  will  usually  be  visible;  and  in  the  cases  of  a 
few  days  standing,  with  marked  destruction  of  tissue,  it  will 
suffice  to  call  them  chronic  for  diagnostic  purposes.  As  a 
rule,  the  history  coupled  with  the  appearance  will  enable  us 
to  malce  a  diagnosis  of  the  case  readily,  though  sometimes 
more  than  one  examination  may  be  necessary.  We  must 
always  remember  not  to  lay  too  much  stress  on  the  history 
given  by  the  patient. 

A  good  working  rule  is  that  all  cases  with  a  plainly  vis- 
ible perforation  may  be  considered  chronic,  and  cases  with 
a  perforation  which  can  only  be  seen  with  difficulty  as  dur- 
■  ig  inflation,  are  acute.  The  beginner  must  be  careful  not 
to  fall  into  the  error  of  taking  redness  as  an  indication  of  an 
acute  condition.  Acute  and  chronic  cases  may  be  further 
subdivided  with  reference  to  the  treatment  into:  first,  op- 
erative cases,  and,  second,  non-operative  cases. 


CHAPTER  VIII. 

THE   MIDDLE   EAR   CONTINUED-ACUTE  PURULENT 

OTITIS  MEDIA. 

Classification  of  Acute  Purdlent  Otitis  Media.— 
In  acute  cases  where  there  u.vs  not  been  a  perforation  the 
appearance  closely  resembles  the  acute  catarrhal  condition, 
and  the  indications  for  treatment  and  surgical  interference 
have  been  referred  to  under  that  subject,  so  that  nothing 
further  need  be  said.  If  a  paracentesis  has  been  performed, 
or  spontaneous  rupture  has  occurred  and  we  have  deter- 
mined that  the   case  is  an  acute  one,  we  must  decide 
whether  or  not  any  further  operative  measures  are  neces- 
sary.   Whether  the  case  is  surgical  or  non-surgical  must  be 
part  of  the  diagnosis.    The  correction  of  any  pathological 
or   abnormal    condition  in   the   nose  or   nasal  pharynx, 
whether  by  treatment  or  operation,  is  of  the  greatest  im- 
portance in  these  cases;  but  this   subject   is  particularly 
treated  in  the  nose  and  throat  department.    In  acute  sup- 
purative otitis  media,   there  are  practically  but  two  op- 
erations to  be  considered,  namely,  the  simple  extension  of 
the  perforation,   and  the  mastoid  operation.    Indications 
for  the  mastoid  operation,  briefly  stated,  are:  any  symp- 
tom pointing  to  intrarcranial  compUcation,  pain  and  tender- 
ness lasting  over  two  days  in  the  mastoid  region,  or  last- 
ing tenderness  without  pain.    This  is,  of  course,  the  briefest 
possible  statement,  and  in  actual  practice  other  things 
must   govern  us  in  our  choice  of  treatment.    The  micro- 

(33) 


1 1, 

..4 


34 


EXAMINATION  OF  THE  EAR. 


scope,  the  clincical  thermometer  and  the  blood  count,  will 
give  us  valuable  hints.  Where  a  trouble  practically  acute, 
as  to  objective  symptoms,  persists,  the  mastoid  operation 
might  be  indicated  without  any  of  the  above  symptoms, 
but  I  believe  that  to  be  of  such  rare  occurrence  as  to  be 
hardly  worth  mentioning,  for  if  such  a  case  were  kept  up 
by  some  condition  in  the  nose,  or  naso-pharynx,  the  cor- 
rection of  this  would  hasten  its  cure,  and  it  could  hardly 
be  kept  up  by  any  condition  in  the  middle  ear  without 
having  to  be  classed  as  a  chronic  case.  Granulations  occa- 
sionally arise  in  acute  cases,  and  when  present  should  be 
removed  or  cauterized.  Of  the  extension  of  the  perforation 
it  is  enough  for  the  purposes  of  this  sylabus  to  say  that 
it  is  indicated  when  the  perforation  present  seems  inade- 
quate for  proper  drainage. 


CHAPTER  IX. 

THE  MIDDLE  EAR  CONTINUED— CHRONIC  PURULENT 

OTITIS  MEDIA. 

Classification  op  Chronic  Purulent  Otitis  Media. 

If  the  trouble  is  classified  as  chronic,  we  should  first  ascer- 
tain whether  there  is  or  is  not  bone  involvement.  In 
chronic  cases  where  the  bone  is  not  involved,  the  surgical 
work  is  much  the  same  as  in  acute  cases.  There  will  be 
necessary  work  in  the  nose  and  naso-pharynx,  and  there 
may  be  granulation  to  be  removed.  An  extension  of  the 
infection  to  the  mastoid  cells  being  in  evidence  their  open- 
ing would  be  called  for.  The  symptoms  that  would  indi- 
cate the  necessity  for  such  measures  would  be  those  men- 
tioned under  acute  cases;  indeed,  it  would  probably  be  an 
acute  axascerbation  of  a  chronic  mastoiditis.  Where  no 
acute  condition  is  present,  the  indication  for  the  mastoid 
op'-ation  would  necessarily  be  very  indefinite.  If  a 
chronic  purulent  process  has  continued  for  a  long  period 
in  spite  of  the  removal  of  all  nasal  obstruction,  and  the 
discharge  is  profuse,  the  opening  of  the  mastoid  antrum 
may  be  '  4fied;  but  such  cases  are  very  rare,  especially 
where      -       las  been  proper  treatment. 

Wht  'e  bone  is  involved  the  diagnosis  becomes  an 
even  mv,.>  important  and  complicated  matter,  and  the  de- 
termination of  what  surgical  interfereuv^e  is  necessary-,  if 
any,  is  a  matter  for  serious  thought. 

The  appearftnce  of  the  parts  will  materially  aid  us  in 
our  diagnosis.    The  location  of  the  perforation  and  the  ex- 

(35) 


! 


I 


36 


EXAMINATION  OF  THE  EAR. 


tent  of  the  perforation  are  the  first  things  that  engage  our 
attention.  Granulations  and  polypi  must  always  be  re- 
moved. These  interfere  with  <^hc  complete  diagnosis  and 
constitute  an  obstruction  to  free  drainage.  Where  there  is 
no  bone  involvement  the  perforation  is  most  probably  in  the 
anterior  portion  of  the  drum,  or,  if  posterior,  it  will  be 
situated  rather  inferiorily  (inferior-posterior  quadrant).  It 
is  most  often  just  at  the  aural  end  of  the  eustachian  tube. 
When  the  position  of  the  perforation  approaches  the  bony 
connection  of  the  drum  membrane  it  suggests  bone  in- 
volvement. The  location  of  the  perforation  in  these  con- 
ditions will  give  us  a  hint  as  to  what  this  bony  involve- 
ment is.  For  example,  when  we  find  the  drum  mem- 
brane intact  except  for  a  perforation  in  Schrapnell's  mem- 
brane (a.  b.  c),  we  may  be  sure  that  the  seat  of  the 
trouble  is  in  the  attic.  If  the  perforation  is  in  front 
of  and  above  the  short  process  of  the  malleus  (c.) 
the  head  of  the  hammer  is  alone  involved;  if-  behind  the 
short  process  in  the  membrana  flaccida  (b.)  the  body  of  the 
incus  is  affected;  if  directly  above  the  short  process  of  the 
malleus  (a.)  most  probably  both  ossicles  are  carious.  When 
the  perforations  in  the  flaccid  membrane  extend  to  the  per- 
iphery, there  exists  most  probably  caries  of  the  bony  wall 
of  the  attic.  In  connection  with  a  perforation  in  Schrap- 
nell's membrane  there  may  be  a  perforation  in  the  mem- 
brana vibrans.  Where  there  is  no  perforation  in  the  flaccid 
membrane  the  location  of  the  opening  in  the  vibrating 
meir.brane  has  also  an  important  bearing  on  the  location  of 
caries.  If  the  perforation  is  in  the  upper  posterior  quad- 
rant (d.)  it  indicates  caries  of  the  long  process  of  the  incus. 
When  a  great  kidney-shaped  perforation  exists  through 
which   the  handle  of  the    hammer  protrudes  from  above 


^  P', 


:« 


wauMawraas  <»r  m  h^b. 


*' 


II  Si 

i 


im^otiim  puforfttioB  «i«  the  tet  ty^i  th»t  M»g«^  ^C, 
fttmtkm.    GraaulAtions  and  polgrpi   aiugft  atwayi  be  ^, 
itoired.    These  interfeie  wiUi  the  eompJete  diegmMie 
ooBstitirte  en  ohsteuction  to  free  dnOnage.    Whera  there  it 
BO  hone  involvement  the  perforation  is  most  im>bi^Iy  in  the 
ttteriof  portion   of  the   drum,  or,  if  posterior,  it  wiU  be 
situated  rath«  inferiorily  (inferior-posterior  quadrant).    It 
is  most  (rften  just  at  the  Aural  end.  of  the  eustachian  tube. 
When  the  position  of  the  perforation  approaches  the  bony 
otameetion    of  the  drum  membrane  it  suggests  bone  itt- 
volvemeat.    The  location  of  the  perforation  in  theee  eo»- 
ditione  trill  give  us  a  hint  as  to  what  this  bony  involve- 
ment is.    For  example,  when  we  find  the    drum   mera* 
braiie  intact  except  for  aDerforalion  in  &ehra|>MU<rinei»^ 
brane    (a.  b.  c),  we  mlj^  sUhj  that  the  seat  of   the 
^'^"MfciMsa^  vtfete««tf 0theI|olblio9ei«>plMv<lMk  ifrdUp 
"ii MA iillWgPctfWtt<^hapt  omUMMdiii   the  %iaUeiM    (c.) 
the  head  of  the  hammer  is  alone  involved;  if*  behind  tho 
short  process  in  the  ihembrana  flaccida  (b.)  the  body  of  tiie 
incus  is  affected;  if  directly  above  the  short  process  «rf  the 
malleus  (a.)  most  iffobably  both  ossicles  are  carious,    Wh«i 
the  perforations  in  the  flaccid  membrane  extend  to  the  pet^ 
iphery,  there  exists  most  probably  caries  of  the  bony  waD 
of  the  attic.    In  connection  with  a  perforation  i&  Sehn^ 
nell's  membrane  there  may  be  a  pwforation  in  the  mttft- 
brana  vibrans.    Where  there  is  no  perforation  in  the  flMeid 
meottbrane  the  location  of  the    opening  in  the  vibntiag 
membrane  has  also  an  important  bearing  on  the  location  ef 
caries.    If  the  perforation  is  in  the  upj^t  posteriOT  quad- 
rant (d.)  it  indicates  caries  of  the  long  proecM  of  ^m  iaeus^ . 
When  a  great  kidney-shaped  perforattoa  exists   throi^ 
tH^h  the  ha&dle  of  tiie   hamraw  promuies  horn  «boT«  ~ 


I-'.' 


THE  MIDDLE    EAR-CHRONIC   PURULENT   OTITIS  MEDIA.     37 

(e  )   the  handle   itself  is  carious.     Where  there  is  a  laree 
defect  (f.)  with   granulations  in    the  upper   posterior  por- 
tion, or  where  a  drop  of  pus  persists  in  this  locality,  even 
after  It  has  been  mopped  off,    caries  of  the  incus  exists. 
In  addition  to  the  defects    of  the  drum  there  may  be  an 
entire  absence  of  all  visible  portions  of   the  ossicles,   and 
more  or  less  of  the  outer  attic  wall  may  be  lacking     It  is 
important  to  note  the  presence  of  cholesteatoma  and  the 
presence  and    location   of  granulations.    The    diagnosis  is 
made  from  the  appearance  of  the  middle  ear,  and  may  be 
confirmed  by  the    probe,  which  enables  us    readily  to  feel 
the  portions  of  bare  bone. 


1W 


.i'.'i 
•2s 


CHAPTER    X. 

THE  MIDDLE  EAR  CONTINUED-OPERATIONS  IM 
CHRONIC  SUPPURATIVE  OTITIS  MEDM 

way  what  m.y  ea„  fo/any  i"  HZ  '„"p:'atr'  ''°"""'' 

1.    The  Simple  Mastoid w^  «« 

toid  operation  in  ^^Z^cJ^^'^ZttZ''  T"" 
s've  operation  is  indicated,  we  deemT^.^  uf^  '^'^"" 
short  of  tlie  radical.  However  1«  """'™«'"«  »» "op 
eration  between  the  .imLu  '.  1^'^  '  compromise  op- 
been  advised7n  Z?^  Tl"^  '""  ^  ^""ical  h« 
this  purpose  leavirint^  '  T  ™  """  *"^"'"^'  '<» 
membrane   and  3«1,k  '"'''''"'   ""^  <'™°> 

superior  wall  of  trcl^;,.*™*''    """""'"«  the  posterior 

Hous  i^ iTn^rdinT^birr  i^r' "'^  -  - 
:~i:tsi  t  rr""^^- -" 

fore  resorting  to  mr';a^  ^1^^^'^  ^removed  be- 
these  may  aid  hearing  wherP  ^TJ  •       ^  removal  of 

rative  ca.es;  but  too'  much  ltd"  T  K  "  ^'^'^^PP"- 
such  is  not  always  the  Zse  ^  P'°™«^^'  «^ 

3.    Exenteration  OF  Outer   Attic  Watt      wu       . 
involvement  seems  more   extensit  /h    ^^^^--^hen  the 

but  the  radical  is  not  posit^r ^dicat^^^^  '"*  "^'"'"'^^^' 
(38)  ^  '^  indicated,  we  may  remove 


lactic      Th«  n^ii'         .    '".""  P"""™  '«"'   ">•  Praphy. 
mcnc.     He  positive  indications  are  those  where  ih^.tZ 

requires  careful,  conscientious  thought  L  tTwhat  ii  th« 
patient's  best  interests.  s  "  ««  to  wnat   is  the 

gul^rtoTtLt  !;"^'-^f  ,^«  ^°^  the  purpose  of  acting  as  a 
guiae  to  attain  a  general  knowledge  of  ear  work  ^nH  ««! 
m  any  way  to  supplant  the  regular  text-LkTon  th^  T 
ject,  or  to  equip  a  finished    siScialist     tT^^  .  .       u"^ 


^ 


CHVPTFR  XI. 


m) 


tn 


'U 


N 


THE  INTERNAL  EAR. 

Only  a  few  words  need  be  said  in  regard  to  the  diseases 
encountered  in  this  region,  a/vi  wi 'ts  in  diagnosis. 

LABYRiNTHiTif  —Primary  iiifliirjni'  tion  of  the  labyrinth 
is  very  rare.  The  symptomF  we  th^^se  of  meningitis  in  a 
milder  form  and  running  fv  ,  i  rt^  course.  Secondary  in- 
flammation of  the  labyrinth,  both  •-  suppur  tive  and  non- 
suppurative cases,  will  be  of*ea  nioi,  with  and  must  be 
looked  for;  it  occurs  much  more  freqi  en^'y  in  chronic  than 
in  acute  forms  of  middle  ear  disease,  lu  non  -uppurative 
conditions  of  chronic  otitis  we  will  rely  'argely  on  the 
hearing  tests  to  determine  whether  the  lab  mth  is  affected 
or  not.  In  suppurative  processes  we  will  tmd  sudden  a- 
ternal  ear  deafness  associated  with  tinnitus  and  ^ertigo, 
and  symptoms  similar  to  those  of  cerebellar  abscess,  devel- 
oping during  a  middle  ear  suppuration. 

Anemia  and  Hyperemia  of  thf  Lahyrimh  -These  are 
rather  symptoms  of  general  conditions  thai  disf  ses 
of  themselves. 

Meniere's  Disease. — Meinere's  diseasf  is  occasionally 
met  with.  Tl':  diagnosis  is  comparatively  eas  The  prin- 
cipal point  is  the  sudden  onset  of  the  symptoms,  u  hich  are 
vertigo  and  tinnitus  associated  with  a  high  degree  ■  :  deai- 
ness,  and  these  by  all  tests  will  prove  t'?  be  limitec*  to  the 
intsjrnal  ear. 
(40) 


THE   INTERNAL   HAK. 


41 


Syphilis  of  the  Internal  i^ar. — The  deafneas  in  this 
condition  will  be  constant,  and  it  will  have  come  on  sud- 
denly without  a^v  middle  ear  disease  ^  receding  it.  The 
history  of  the  c;  and  other  evidences  of  the  existence  o*' 
yphilis  Afc  11  aid    is  in  our    liagno. : 

Labyrinthine  diseaseh  isaor  i  wiiii  deafness  may  be 
recognized  by  thu  teste  for  hianug,  and  the  cause  may  be 
obtained  by  soliciting  a  areful  '  story.  In  moF  cases  the 
prognosis  is  bad,  uut  appropriate  tr  atment  should  be  Ui- 
dti  luted. 


CHAPTER   XII. 


I.  Tt 


HEARING  TESTS. 

First,  the  hearing  distance  for  the  whispered  voice  should 
be  obtained  for  each   ear.    This  is  comparatively  a  rough 
test  but   a   most  important  one,  and  in  many    ways  the 
best.     In  testing  with  any  noise-producing  instrument  one 
cannot  be  perfectly  sure  at  what  distance  the  patient  first 
hears  the  sound,  not  even  the  patient  himself.     This  is 
especially  true  in  the  case  of  children.    If,  however,  the 
patient  is  made  to  repeat  a  whispered  word  or  figure  it  is 
certain    that  he  cannot    repeat  without  hearing.     Several 
words  may  be  used  to  eliminate  the  element  of  guessing, 
and  for  fear  of  lip  reading  the  mouth  should  bo  kept  from 
the  patient's  view.    This  test  is  not  absolutely   accurate, 
for  the  voice   may  be  louder  at  one  time  than  at  another; 
but  if  the  lungs  are  emptied  by  an  expiration  it  will  force 
the  voice  to  a  whisper.    It  is  well  to  use   numbers  and  to 
note  what  numbers  are   used  in   each  case,  as  the  tones 
differ.     In  addition  to  the  voice  we  will  use  the  watch  for 
the  distance  tests.     Watches  differ  in  pitch  and  are  usually 
compound  in   tone.    Often   persons  of    advanced  age  do 
not  hear  the  watch  unless  almost  in   contact  with  the  ear, 
and  this,  notwithstanding  the  fact  that  in  case  of  the  voice 
test  the  hearing  seems  almost  normal.    Hearing  deteriorates 
with  advancing  age,   and  this  deterioration  is  in  the  high 
tones.    Having  noted  in  this  way  the  extent   of  impair- 
ment the  tuning  fork  must  be  used.    By  its  use  we  may  de- 
(42) 


HEABING  TESTS. 


43 


termine  whether  the  deafness  is  limited  to  the  middle  ear, 
or  whether  the  nerve  is  involved. 

Fork  Tests. — ^We  should  first  of  all  determine  whether 
the  hearing  is  better  for  the  high  or  the  low  tuning  forks. 
Persons  with  normal  hearing,  and  those  with  middle  ear 
deafness,  hear  high  tones  better  than  1'  7  tones;  but  where 
deafness  is  limited  to  the  sound  perceiving  apparatus  the 
opposite  is  true.  We  should  know  about  how  long  the  fork 
we  are  using  is  heard  by  the  normal  ear  and  time  care- 
fuUythe  air  conduction  for  at  least  one  high  and  one  low 
fork. 

Rinne's  Test. — The  Rinne  test  is  perhaps  the  most 
helpful  one  to  resort  to  after  we  have  determined  whether 
the  hearing  is  better  for  the  high  or  low  tuning  forks.  In 
making  this  test  the  low  toned  fork  is  placed  on  the  tip  of 
the  mastoid  process  and  held  there  until  the  sound  is  heard 
no  more;  then  the  fork  is  .inmediately  placed  in  front  of 
the  meatus,  and  if  the  patient  again  hears  the  fork  the  test 
is  positive;  if  the  fork  is  not  heard  again  the  Rinne  is  nega- 
tive. A  positive  Rinne  indicates  that  the  hearing  is  bet- 
ter by  air  conduction  than  by  bone  conduction.  This  is 
true  in  the  normal  ear  and  where  the  hearing  is  only 
slightly  affected.  Where  the  hearing  is  markedly  impaired 
a  negative  Rinne  indicates  a  middle  ear  deafness,  and  a 
positive  Rinne  an  internal  ear  deafness. 

Weber's  Test. — When  one  ear  is  more  affected  than  the 
other  the  fork  is  placed  on  the  middle  of  the  forehead  and 
the  patient  is  asked  in  which  ear  it  is  most  distinctly  heard. 
If  in  the  well  ear  it  indicates  that  the  trouble  in  the  affected 
ear  is  limited  to  the  sound  perceiving  apparatus.    If  more 


44 


EXAMINATION  OF  THE  EAR. 


111 


re. 


distinctly  in  the  affected  ear  it  indicates  that  the  trouble  is 
a  middle  ear  deafness. 

The  above  tests  are  all  that  will  be  needed  in  our  clinical 
work.  More  elaborate  tests  can  be  undertaken  by  those 
wishing  to  specialize. 


CHAPTER  XIII. 


INTRA-CkANIAL  COMPLICATIONS. 

A  word  should  also  be  said  about  intra-cranial  complica- 
tions so  that  such  may  be  looked  for  and  recognized.  It  is 
not  practicable  to  go  at  length  into  the  discussion  on  the  di- 
agnosis of  all  intra-cranial  complications  of  otitic  origin  in  a 
work  of  thiS  scope,  but  we  shall  merely  mention  the  forms 
of  intra-cranial  involvement  and  state  what  the  suspicious 
symptoms  of  such  are. 

Facial  Nerve  Paralysis. — ^This  condition  may  occur  as 
a  complication  of  acute  otitis  media,  acute  and  chronic  pu- 
rulent otitis  media,  and  may  be  associated  with  a  chronic 
non-suppurative  otitis  media.  The  diagnosis  is  most  simple 
and  the  presence  of  a  facial  paralysis  can  hardly  be  over- 
looked. The  face  is  drawn  to  the  unaffected  side,  and  the 
eye  on  the  affected  side  usually  remains  open  while  the 
other  winks.  If  the  patient  attempts  to  whistle  or  to 
smile,  the  unevnenss  of  the  face  may  be  readily  marked. 
The  ears  should  be  examined  in  all  cases  of  facial  paralysis 
even  if  they  are  supposed  to  be  unaffected.  If  the  paraly- 
sis is  associated  with  an  acute  condition  with  an  intact 
drumhead,  a  paracentesis  should  be  performed  at  once.  If 
the  paralysis  is  a  complication  of  a  chronic  suppurative 
condition  with  caries,  and  if  it  persists,  it  would  call  for  the 
radical  mastoid  operation. 

Meningitis. — The  temperature  is  high  without  marked 
remissions;  the  pulse  is  usually  rapid.    Headache  may  be 

(45) 


46 


EXAMINATION  OF  THE  EAR. 


'i 

...I 


!r 


Ih-: 


either  localized  or  diffuse.  Vomiting  is  commonly  ft 
symptom.  The  respiration  is  of  the  Cheyne-Stokes  variety. 
There  is  usually  rigidity  of  the  neck.  Signs  of  general  de- 
bility appear,  then  delirium,  and  finally  coma.  The  eye 
symptoms  are  strabismus,  pupils  contracted  or  dilated, 
and  usually  choked  disk  or  retinitis.  Epidural  Abscess, 
shows  symptoms  like  the  above  but  the  symptoms  of  ab- 
scess pressure  are  more  defined.  The  pulse  rate  is  slower 
and  the  temperature  is  not  high,  it  may  be  sub-normal. 
Vomiting  may  occur,  and  sickness  and  general  stupor  may 
follow. 

Brain  Abscesses  are  located  either  in  the  tempo-sphe- 
noidal  lobe  or  the  cerebellum  of  the  diseased  side,  some- 
times in  both.  Temperature  sub-normal  or  only  slightly 
raised,  may  be  high  at  onset.  Pulse  is  slow^.  Headache 
and  vomiting  are  often  present  but  may  be  absent.  Ba- 
binski's  sign  may  be  present  but  is  not  constant.  Respira- 
tion is  normal  or  slow  and  may  be  of  the  Cheyne-Stokes 
variety.  Eye  symptoms,  retinitis  or  choked  disc  may  be 
present,  pupils  are  contracted  and  often  unequal.  There  is 
mor*»  or  less  stupor,  slowness  of  speech  and  mental  dulness 
which  may  end  in  coma. 

Sinus  Thrombosis. — Temperature  high  with  repeated 
drops  in  temperature,  oscillating.  Rigors  and  profuse  pers- 
piration. Pulse  is  usually  rapid.  Respiration  rapid  or  of 
Cheyne-Stokes  variety.  Sometimes  stiffness  of  the  neck 
and  often  tenderness;  tenderness  over  mastoid  region. 
Optic  neuritis.  Blood  shows  increase  of  white  corpuscles. 
There  is  usually  great  depression  and  metastatic  phenom- 
ena may  be  manifested. 


CHAPTER  XIV. 

EXERCISES    IN  THE  SURGICAL  ANATOMY  OF    THE 
TEMPORAL  BONE. 

As  anatomy  is  the  foundation  of  medical  science,  a  gen- 
eral knowledge  of  this  subject  is  indispensable  to  the  physi- 
cian, be  he  general  practitioner,  surgeon  or  specialist;  but 
to  the  aural  surgeon  an  accurate  knowledge  of  the  anatomy 
of  the  temporal  bone  is  an  essential  factor. 

This  accurate  knowledge  is  to  be  attained  by  careful 
reading  and  by  study  of  the  bone  itself  and  sections  of  it. 
If  sections  of  the  bone  for  purely  anatomical  study  be  made 
by  the  student  himself,  his  idea  of  the  relations  in  which 
tho  several  component  parts  stand  will  be  clearer  and  more 
exact,  and  this  clearness  and  exactness  is  a  necessary  attri- 
bute of  the  surgeon. 

In  the  exercises  here  set  out  the  student  is  to  apply  this 
anatomical  knowledge  which,  it  is  presupposed,  he  has  al- 
ready acquired.  His  knowledge  of  the  anatomy  of  the  tem- 
poral bone  can  now  be  applied  in  studying  the  surgery  of 
this  region. 

The  prime  object  of  this  short  sketch  is  to  describe  very 
briefly  some  exercises  in  a  course  which  is,  as  I  have  said, 
fundamental  to  the  study  of  otology.  It  should  be  borne 
in  mind  that  these  are  exercises  in  applied  or  surgical  anat- 
omy and  that  previous  preparation  in  the  anatomy  of  the 
temporal  bone  is  necessary.    The  first  three  exercises  will 

.  (47) 


48 


EXAMINATION  OF  THE    EAR. 


U* 
^ 


II  ^ 


I- 


be  devoted    mainly  to  a  review  of  certain  conditions  and 
relations  from  an  anatomical  point  of  view. 

For  these  exercises  it  is  necessary  to  be  supplied  with 
human  temporal  bones  previously  removed  from  the 
skull  with  saw  and  chisel  and  preserved  in  60  per  cent. 

alcohol. 

The  pinna  must  be  removed  but  the  other  soft  parts  left 
in  place,  the  cartilaginous  portion  of  the  external  auditory 
meatus  and  the  skin  lining  the  meatus  being  intact.  If 
the  specimens  are  hard  when  taken  from  alcohol  they 
should  be  left  in  water  twenty-four  hours  before  using. 

A  general  rule  of  procedure  with  these  specimens  is 
first  to  clean  out  carefully  any  dirt  or  foreign  matter  that 
may  be  in  the  external  auditory  meatus  and  then  to  examine 
with  a  speculum,  always  noting  the  condition  of  the  drum- 
head. All  work  must  be  done  under  strong  light  reflected 
from  a  head-mirror.  The  light  from  a  Welsbach  burner  is 
especially  suitable  because  of  its  brightness. 

The  necessary  instruments  are  a  mallet  (wood  preferable 
on  account  of  its  size  and  weight),  a  set  of  chisels,  of  gouges, 
a  surgical  knife,  a  periosteal  elevator,  a  paracentesis  needle, 
one  or  two  probes,  a  tenatome,  a  tenatome  sound,  Zeronii's 
incus  extractor  and  pincettes  and  forceps.  In  working 
with  the  chisels  or  gouges  the  preparation  must  be  made  fast 
in  a  vise,  the  external  surface  pointing  upward.  The  posi- 
tion may  be  changed  to  suil  the  comfort  of  the  student, 
but  the  bone  must  always  be  fast  and  in  such  a  position  as  to 
receive  the  light  reflected  from  the  head-mirror  on  the  field 
of  operation.  The  chisel,  or  gouge,  should  always  be  started 
at  a  steep  angle,  turning  sharply  after  the  first  blow.  Jhis 
first  steep  placing  is  very  aptly  termed  by  Prof .  Grunert,"  the 
paradox  position,"  so  called  because  if  the  chisel  were  driven 


SURGICAL  ANATOMY   OF  THE   TEMPORAL  BONE. 


49 


in  as  placed  it  would  enter  parts  that  it  is  not  meant  to  enter. 
In  the  neighborhood  of  the  sinus,  however,  the  chisel  should 
be  placed  flat.  When  working  from  within  outward  the 
probe  should  always  be  used  to  feel  behind  any  prominence 
to  determine  whether  it  may  be  removed  without  endanger- 
ing any  important  parts. 

The  first  three  exercises  will  be  devoted  to  reviewing 
conditions  and  relations  without  particular  regard  to  sur- 
gical technique.  But  in  the  r  raaining  exercises  careful  at- 
tention must  be  paid  to  the  technique  as  being  of  greatest 
importance. 

First  exercise.  After  having  properly  cleaned  out  the 
meatus  as  suggested,  the  following  points  should  be  noted: 
In  the  osseous  portion  of  the  external  auditory  canal  the 
skin  is  very  thin  and  smooth,  and  there  are  no  glands  or 
hairs  present.  Furuncle  does  not  occur  in  this  portion.  An 
abscess  might  resemble  a  furuncle,  but  must  not  be  mis- 
taken for  it.  The  narrowest  portion  of  the  canal  is  about 
the  middle,  and  the  osseous  portion  is  narrower  than  the 
cartilaginous  portion.  The  lumen  is  oval,  its  greatest  diam- 
eter being  superior-inferior.  The  inferior  and  anterior 
walls  of  the  canal  are  longer  than  the  superior  and  posterior. 

Now,  the  drumhead  should  be  examined  and  its  principal 
points  reviewed,  recalling  also  its  position  and  angle.  It 
forms  an  obtuse  angle  with  the  posterior  wall  and  an  acute 
angle  with  the  anterior  wall.  It  is  important  to  bear  this 
in  mind  when  removing  foreign  bodies.  If  the  drumhead 
is  normal  its  color  is  pearlish  gray.  The  short  process  of 
the  hammer  is  plainly  seen  and  the  hammer  handle  run- 
ning downward  and  backward  from  it  to  the  central  point, 
which  is  called  the  umbo.  From  the  umbo  downward  and 
forward  shines  the  cone  of  light  with  its  apex  towards  the 


<^l 


50 


EXAMINATION  OF  THE  EAR. 


1 
11* 


lu 
ft 


Ik 


umbo  and  its  base  bounded  by  the  periphery  of  the  drum- 
head. Schrapnell'a  membrane  and  the  anterior  and  poster- 
ior folds  are  seen,  and  when  the  drumhead  is  thin  and 
transparent  the  long  process  of  the  incus  shows  through, 
not  parallel  to  hammer  as  shown  in  some  plates,  but  converg- 
ent to  it.  Very  seldom  the  chorda  tympani  nerve  is  seen 
through  the  drumhead  running  in  front  of  the  bony  process 
of  the  incus  and  just  below  the  margo  tympani. 

At  this  point  the  cartilaginous  canal,  the  skin  covering 
it  and  the  bony  canal  should  be  removed,  care  being  taken 
not  to  disturb  the  drumhead.  With  a  paracentesis  needle 
a  cut  is  now  made  in  the  drumhead,  semi-circular  in  shape, 
extending  from  a  point  directly  behind  the  hammer,  as  far 
above  and  in  front  as  possible,  to  the  middle  point  below, 
following  the  periphery  of  the  drumhead  posteriorly. 


Fig.  1. 
Right  drum-head,  dotted  lines  showing- 
ing  position  of  incision. 


Fig.  2. 
Showing  the  loose  flap  folded  forward 
on  to  fixed  portion. 


In  Fig.  1  the  dotted  lines  show  the  position  of  the  incision 
in  a  right  ear-drum.  Now  fold  this  loose  flap  forward  on 
the  anterior  portion  of  the  drumhead  as  shown  in  Fig.  2. 
This  brings  into  view  the  posterior  portion  of  the  inner 
wall  of  the  tympanum.  One  now  sees  plainly  the  promon- 
tory across  which  superioriy-inferioriy  runs  Jacobson's 
nerve.    The  long  process  of  the  incus  is  plainly  visible,  and 


SURGICAL  ANATOMY  OP  THE  TEMPORAL  BONE.    51 

by  tilting  the  bone  the  chorda  tympani  nerve  can  be  seen 
passing  before  it  under  the  margo  tympani.     Dimly  behind 
the  long  process  of  the  incus  a  portion  of  the  stapes  is 
seen,  the  stapedius  muscle  somewhat  limiting  the  view. 
The  niche  to  the  round  window  is  inferior  and  posterior  to 
the  stapes.    The  rough  condition  of  the  bony  floor  of  the 
tympanum  is  worthy  of  notice.    In  front  of  the  base  of  the 
stapes  the  processus  cochlearis  may  be  seen  with  some  dif- 
ficulty.   The  points  mentioned  in   this  exercise  may  be 
profitably  reviewed  before  taking  up  the  second  exercise. 
Second  exercise.    In  the  same   specimen  the  student 
should  now  proceed  to  lemove  with  the  chisel  and  mallet 
the  roof  of  the  bony  canal,  working  from  within  outward, 
and  remembering  what  has  been  said  about  the  use  of  a 
probe  and  the  position  of  the  chisel.    The  outer  wall  of  the 
attic  is  thus  removed  and  the  contents  of  this  cavity  are 
now  brought  into  view.     (The  attic  extends  externally  oyer 
the  roof  of  the  external  canal  and  also  behind  the  posterior 
wall  of  the  canal.)    The  head  of  the  hammer  is  seen  and  its 
articulation  with  the  incus,  of  which  ossicle  we  can  now  see 
the  whole  body  and  the  short  as  well  as  the  long  process. 
Inferior  and  inteiior  to  the  short  process  of  the  incus  and 
on  the  inner  wall  is  the  canalis  Fallopii,  falsely  called  aque- 
ductus  Fallopii,  seen  as  a  thick,  white  line.    In  this  passes 
the  facial  nerve.    The  canalis  Fallopii  is  immediately  su- 
perior in  position  to  the  stapes.    In  this  location  congenital 
defects  are  often  present,  and  facial  paralysis  is  caused  by 
pressure  in  cases  of  purulent  otitis  media.    With  a  probe  it 
is  very  easy  to  enter  the  mastoid  antrum,  behind  the  attic, 
and  by  tiltiu?:  the  bone  in  the  proper  direction  light  may  be 
reflected  into  the  antrum,  but  the  view  that  this  affords  is 
only  a  limited  one. 


52 


EXAMINATION  OF  THE    EAR. 


Before  finishing  witli  this  exercise  the  cellular  condition 
of  the  roof  of  the  attic  is  to  be  noted  and  particularly  the 
position  of  the  horizontal  semi-circular  canal  which  is  above 
and  behind  the  canalis  Fallopii. 


1^1 


Fig.  3.     Diagrammatic  drawing  to  show  the  position  of  the  planum 
mastoideum  and  opening  into  antrum. 

Third  exercise.  As  the  work  on  this  first  specimen  is 
chiefly  to  review  one's  knowledge  of  general  relations,  it 
will  be  completed  by  locating  and  entering  the  antrum 
from  without.  The  bone  may  be  further  cleaned  of  its  soft 
parts  with  a  scalpel  and  a  periosteal  elevator. 

Locate  now  on  the  exposed  bone  the  linea  temporalis,  the 
spina  supra  meatum  and  the  line  of  attachment  of  the 
sternocleido-mastoid  muscle.  Lines  may  be  marked  for 
convenience  with  a  blue  pencil.  Fig.  3  is  verj-  diagrama- 
tic,  a  line  being  added  behind  to  complete  the  boundary 
of  the  plane.    The  surface  marked  out  by  these  lines  is  the 


SURGICAL  ANATOMY  OF   THE  TEMPORAL  BONE. 


53 


planum  mastoidem  and  in  the  center  of  this  plane  the 
entrance  is  to  be  made  into  the  anti  .m  with  a  gouge  and 
mallet,  following  the  direction  of  the  external  auditor>- 
meatus  downward,  forward  and  inward.  As  the  opemng 
in  this  case  is  only  to  locate  the  antrum  it  should  not  be 
much  larger  than  to  admit  the  gouge  with  which  it  is  made. 
The  position  of  the  horizontal  semi-circular  canal  is  to 
be  especially  noted  through  this  opening.  The  first  speci- 
men is  now  ready  and  should  be  saved  as  a  remmder  of 
the  steps  taken  in  its  preparation.  In  all  of  these  exercises 
it  is  well  to  save  the  specimens  when  they  are  finished 
and  when  they  show  nothing  of  particular  interest  they 
may  be  worked  out  further  as  anatomical  specimens. 

Fourth  exercise.  In  all  the  following  exercises  more  or 
less  attention  is  to  be  paid  to  the  surgical  technique;  but  in 
the  present  exercise  the  technique  of  the  operation  is  to  be 
carefully  observed  beginning  with  the  initial  incision  in  the 

soft  parts.  .  ,    ,        J.       1 

The  bone  must  be  made  fast  in  the  vise  with  the  external 
surface  upward,  after  having  been  cleaned  and  the  drum- 
head examined  as  mentioned.     The  initial  incision  is  then 
made  from  a  point  superior  and  a  little  anterior  to  the  ex- 
ternal auditory  meatus  extending,  semi-circular  in  shape, 
almost  to  the  tip  of  the  mastoid  process.    See  Fig.  4.    The 
incision  must  be  made  through  the  soft  parts  to  the  bone, 
except  above,  where  care  must  be  taken  not  to  cut  the 
temporal  muscle.    In  using  the  scalpel  the  cutting  should 
be  done  with  the  edge  of  the  blade  and  not  with  the  point. 
With  the  periosteal  elevator  the  bone  ruist  now  be  laid  bare, 
forward  to  the  edge  of  the  bony  meatus  and  to  the  root  of 
the  zygomatic  process,  and  backward  to  a  distance  of  from 
a  half"  to   three-quarters   of   an  inch.    Caution   must  be 


54 


EXAMINATION   OF   THE    l  VB. 


Li 
4 

M 


exercised  in  using  the  periosteal  elevator.  The  thumb 
should  be  placed  near  the  point  >  guide  tho  instrument  and 
to  guard  against  using  of  too  great  force  which  might 
be  very  dangerous,  especi:  lly  in  rachitic  children  where  the 
bone  is  softened. 


Fig.  4.    Relation  of  initial  incision  to  external 
meatua  and  mastoid  process. 


The  planum  mastoideum  as  described  in  the  last  exercise 
must  be  marked  again.  It  is  well  to  mention  here  that  the 
relation  of  the  lines  described  ma""  oonetimes  give  valuable 
hints  as  to  the  positions  of  the  ran;.  1  f<  ssa  and  the  sig- 
moid sinus.  When  the  positions  of  theae  important  points 
are  normal  a  line  drawn  through  the  spina  supra  meatum 
would  about  cut  the  planum  mastoideum  in  two  equal  parts. 
Should,  however,  the  linea  temporalis  lie  so  low  that  a  line 
drawn  through  the  spina  supra  meatum  would  be  very  close 
to  it,  this  would  indicate  that  the  cranial  fossa  reached 
lower  down  than  usual  and  that  the  sinus  was  farther  for- 
ward, hence  calling  for  special  caution. 
;  The  opening  from  without  into  the  antrum  is  begun  by 
removing  the  cortex  for  a  space  taking  up  the  greater 
part  of  the  planum  mastoideum.    In  the  center  of  this 


H&^il 


SURGICAL  ANATOMY  OF  THE  TEMPORAL  BONE.    55 


space  th«  opening  should  be  made  into  the  antrum,  running 
parallr!  to  the  external  auditory  meatus.  Feeling  the  way 
with  the  probe,  the  openmg  should  next  be  carefully  en- 
larged and  should  extend  to  the  tip  of  the  mastoid  process. 
This  process  is  necessary  for  the  proper  drainage  of  pus, 
and  furthermore,  the  walls  must  be  smooth  with  no  rough 
ridges  left  to  hinder  the  outflow.  This  completes  the  open- 
ing into  the  antrum  as  done  in  the  operation  on  the  living 
subject.  See  Fig.  5.  Where  the  point  of  the  mastoid 
process  is  involved  the  entire  point  may  be  chiseled  away. 
The  best  drain  in  these  cases  is  a  t  lall  rubber  hose. 


Fig.  6.    Simple  opening  into  tbf  •"'trum  m 
operation  ia  oociioflted. 


after  the 


Fi  th    exercib.      This    consists    in   p    .  >   riing    wha*,   is 
falsely  called  the  "radical  operation."     •     .  a  radical 

operation  for  the  reason  that  in  every  csj  '.  .1  diseased 
parts  are  removed.  It  is  really  a  complete  c  :..ng  into  the 
middle  ear  and  in  the  clinic  at  Halle  the  term  "Total- 
aufmeisselung"  has  been  adopted.  The  work  on  this  opera- 
tion for  the  complete  opening  of  the  middle  ear  will  be 
continued  on  the  same  preparation  -ised  in  the  '■^"•it-  es-ercise. 

The  bridge,  or  strip  of  bone  between  the  ra'.  t>As;^and  the 
artificial  opening,  is  to  be  removed.    The  iarge^gouge  is 


56 


EXAMINATION    OF  THE    EAR. 


Hi 
V 


hi 


to  be  used.    The  work  is  wedge-shaped,  broad  without  and 
becoming   narrower   as   it   progresses   inward.    After   the 
bridge  is  broken  through  below,  the  cavity  should  be  care- 
fully enlarged.    Always  sound  with  the  probe  before  mak- 
ing a  cut  with  the  gouge,  and  after  each  cut  the  splinter  of 
bone  as  it  is  loosened  should  be  removed.    When  possible, 
it  is  well  to  throw  out  the  piece  of  loose  bone  with  the 
chisel  after  each  stroke.    This  artificial  opening  should  now 
form  one  large  cavity  with  the  meatus;  the  walls  must  be 
smooth  and  free  from  ridges  and  prominences.    The  sig- 
moid sinus  must  be  avoided,  and  care  should  be  taken  not 
to  injure  the  horizontal  semi-circular  canal  or  the  facial 
nerve.    It  may  be  mentioned  here  that  the  facial  nerve  lies 
more  externally  below  than  it  does  above,  so  that  if  a 
probe  were  placed  on  the  aditus  of  the  antrum  the  part  of 
the  nerve  above  it  would  lie  median  to  its  point,  while  that 
below  would  be  external  to  it. 

The  hammer  and  incus  must  be  removed,  a  tenotome  be- 
ing used  to  cut  the  tensor  tympani  tendon  before  remov- 
ing the  hammer.  The  stapes  should  always  remain  in  place 
and,  as  far  as  possible,  intact.  It  is  well  to  feel  with  the 
finger  that  the  walls  of  the  cavity  are  smooth  and  without 
marked  ridges. 

Sixth  exercise.  This  exercise  is  to  be  devoted  to  prac- 
ticing the  extraction  of  the  hammer  and  the  incus  through 
the  external  meatus,  and  the  specimen  must  at  first  be  so 
prepared  as  to  allow  the  student  to  follow  the  steps  -  :th 
the  eye.  In  order  to  work  more  freely  the  student  may 
remove  the  soft  parts  when  he  first  attempts  this  exercise. 
The  drumhead,  however,  must  be  left  in  place. 

The  dura  having  been  removed,  an  opening  is  chiseled 
through  the  tegmen  tympani.    This  work  must  be  done 


SURGICAL  ANATOy^   >F  THE  TEMPORAL  BONE. 


67 


lightly  and  carefully,  especial  care  being  taken  not  to  dis- 
turb the  ossicles.    Through  this  opening  the  contents  of 
the  tympanum  and  the  attic  and  their  relations  are  now 
seen     The  different  points  should  be  noted,  but  special 
attention  must  be  paid  to  the  tendon  of  the  tensor  tympani 
muscle,  its  attachment  to  the  hammer  and  its  relation  to  the 
facial   nerve   and   to  the  horizontal  semi-circular  canal. 
Having  fixed  these  points  the  student  may  proceed  to  prac- 
tice the  operation.  ,      j       .     j       j 
First  of  all  comes  the  incision  into  the  drumhead  and 
this  should  be  made  to  surround  the  hammer.    The  first 
cut  is  made  parallel  to  the  hammer  and  immediately  be- 
hind it;  the  next  cut  is  parallel  to  the  hammer  and  in  front 
of  it     These  cuts  extend  as  far  upward  as  possible  and 
are  joined  below  by  a  third  cut.    See  Fig.  6.    This  method 
of  making  the  incision  in  the  drumhead  is  preferable  to  the 
old  method  of  following  the  periphery  because  the  bleeding 


Fl«.«.    Inarightdruin-l».ddotttdl}iiai»howpodtlono»incWoii. 


is  less  profuse;  the  danger  of  the  knife  coming  in  contact 
with  the  margo  tympani  is  obviated  and  the  hammer  is 

easier  to  obtain. 

The  next  step  is  the  locating  of  the  tensor  tympani 
tendon  with  the  tenotome  from  the  outside  through  this 
incision;  and  to  accomplish  this  the  tenotome,  with  the 
cutting  edge  forward  and   the  point  upward,  is  passed 


58 


EXAMINATION  OF  THE   BAR. 


.1 


S; 

Hi 
y 


through  the  uppermost  part  of  the  incision  behind  the  ham- 
mer, in  an  upward,  inward  and  forward  direction  until  its 
further  progress  is  blocked  by  the  bony  wall  of  the  attic. 
Now,  slightly  withdraw  the  tenotome  outwardly  until  the 
point  is  just  free  of  the  bony  wall  and  then  turn  it  forward 
until  it  can  be  felt  to  be  resting  on  the  tendon.    This  should 
be  followed  at  first  by  the  eye  in  the  opening  in  the  tegmen 
tympani,  and  before  cutting  the  tendon  this  location  of  it 
should  be  practiced  again  and  again  until  t^e  student  is 
able  to  realize  by  the  touch  the  position  o^  the  instrument. 
After  sufficient  practice  the  tendon  should  be  cut  by  a  slight 
sawing  motion  of  the  *;notome,  and  the  other  steps  should 
be  taken  up.    The  '    mmer  is  now  to  be  removed,  and, 
with  the  tenotome,  the  handle  is  bent  forward  so  that  a 
wire  snare  may  be  passed  around  the  neck  of  this  ossicle 
and  it  is  withdrawn  by  rotating  it  out  of  its  position  down- 
ward and  outward. 

After  the  hammer  has  been  removed  the  incus  must  be 
attended  to,  and  the  best  instrument  for  this  purpose  is  the 
incus  extractor  which  was  invented  by  Dr.  Zeroni.  The 
instrument  is  so  directed  that  it  rests  where  the  hammer  did, 
the  concave  surface  pointing  toward  the  incus.  The  instru- 
ment is  now  turned  until  the  concave  portion  rests  on  the 
body  of  the  incus,  and  from  this  position  the  extraction  is 
made.  The  obtaining  of  this  position  may  be  practiced  again 
and  again  until  the  incus  is  finally  removed  by  the  same 
motion  as  that  used  in  withdrawing  the  hammer.  When 
the  incus  has  fallen  to  the  floor  of  the  tympanum  it  should 
be  removed  with  a  bent  probe.  The  use  of  the  pincettes 
should  be  avoided. 

This  exercise  is  now  complete;  but  these  steps  should  be 
reviewed  on  a  specimen  in  which  the  tegmen  tympani  has 


SURGICAL   ANATOMY  Or'  THE   TEMPORAL  BONE. 


59 


not  been  opened  and  in  which  all  of  the  soft  parts  have  been 
left  in  place.  This  time  the  work  should  all  be  done  through 
a  speculum,  for  the  sake  of  practice.  If  possible  it  is  well 
to  practice  this  particular  operation  on  the  cadaver  and 
to  have  conditions  as  nearly  as  possible  as  they  would  be  m 
an  operation  on  the  livmg  subject.  The  absence  of  bleed- 
ing, however,  is  one  great  difference. 

Seventh  exercise.  This  exercise  takes  up  the  operation 
after  Stacke,  and  the  initial  incision  in  this  case  is  made 
just  as  it  was  described  in  the  operation  for  the  opemng 
from  without  into  the  antrum.  The  bone  is  now  laid  bare 
with  the  periosteal  elevator  as  far  forward  as  the  root  of 
the  zygomatic  process,  and  in  the  meatus  to  the  drumhead. 
Posterior  to  the  incision  the  soft  parts  should  be  left  ad- 
herent in  this  ci.  v;  as  the  edges  of  the  incision  in  the  soft 
parts  may  be  sewed  together  after  the  operation. 

The  chiseling  is  now  begun  from  within  outward  follow- 
ing the  general  directions  as  given.  This  probe  must  be 
continually  used,  and  every  splinter  of  bone  must  be  re- 


Fi«  7     Dii«r»miMUo  illustrmUon  of  meatus  entanjwi  mcUy  superiorly. 
■  Md  poeteriorly.    Dotted  Une*  .how  outUne  of  oomptote  opemng. 

moved  as  it  is  loosened.  In  this  manner  the  opening  is 
carefully  enlarged  until  the  antrum  and  the  attic  are  well 
exposed.  The  meatus  is  thus  enlarged  especially  superi- 
orly and  posteriorly.  The  walls  of  the  opening  must  be 
smooth  and  even.    See  Fig.  7. 


60  EXAMINATION   OP  THE  EAR. 

Eighth  exercise.  This  consists  in  extending  the  siinple 
Stacke  into  the  operation  for  the  complete  opening.  The 
dark  portion  in  Fig.  7  shows  the  simple  Stacke  and  the 
dotted  lines  show  how  it  i.  to  be  enlarged  to  reach  the 
point  of  the  mastoid  process.  Xae  opening  thus  enlar^ 
must  never  have  a  sharp  angle  as  is  shown  m  Fig.  8a,  but 
must  be  smooth  and  rounded  off  as  in  Fig.  8b.  Fig.  8c 
shows  how  the  work  must  progress  from  within  outward. 


« 


Fig.  8.    Diagnun  illu.tr.Uiig  incon^st  (•)  and  correct  Ort  Bh»pe,  MpeciaWy  of 
the  inferior  border,  of  the  complete  opening. 


i. 


H\ 


I    Antrum.    2.  Meatus.     3.  Probe.    Dii«,«nm.tic  .ketch  showing  the  portion  of 
the  probe  in  funding  before  moving  poeterior  wall  at  W. 

In  SO  enlarging  this  cavity  great  care  must  be  taken  not 
to  injure  the  facial  nerve  and  this  nerve  may  now  be  ex- 
posed at  its  most  dangerous  point,  a  short  distance  below 
the  horizontal  semi-circular  canal.    Above  m  the  neigh- 


SURGICAL  ANATOMY  OF  THE  TEMPORAL  BONE. 


61 


borhood  of  the  semi-circular  canal  where  the  course  of  the 
nerve  may  be  seen  it  is  not  to  be  disturbed,  nor  is  the  semi- 
circular canal  to  be  opened.  The  exposing  of  the  facial 
nerve  which  is  done  further  down  is  to  show  the  danger 
of  coming  in  contact  with  it  in  the  course  of  an  operation 
The  course  of  the  facial  nerve  is  not  always  the  same,  and 
for  convenience  sake  it  may  be  said  that  there  are  two  gen- 
eral types  of  its  courses,  the  steep  and  the  flat.  This  di- 
vision is  not  arbitrary.    Fig.  9a  represents  the  steep  course, 


>. 


O 


a.  Steep. 


d 


b.  Flat. 


Fig.  9.    Diagram  showing  two  types  of  the  course  of  the  facial  nerve. 

where  the  nerve  keeps  behind  the  margo  tympanum  and 
comes  forward  below.  Here  the  danger  of  striking  the 
nerve  is  reduced.  Fig.  9b  represents  the  flat  course  where 
the  nerve  comes  forward  over  the  margo  tympanum.  The 
danger  of  striking  the  nerve  in  this  case  is  increased. 

Fig.  10  is  a  diagram  of  the  flat  form  looking  down  from 


M    Meatus.    N.  Nerve.    T.  Tympanum.    E.  External  Surface. 
Fig.  10.     Diagram  of  flat-rse  "^facial  nejve     ^^|^«,downiroma'^v.^'JS 

nerve  behind. 


62 


EXAMINATION  OF   THE    EAR. 


above.  It  jnows  how  much  longer  a  line  drawn  from  with- 
out to  a  point  in  the  course  of  the  nerve  in  front  of  the 
meatus  is  than  a  similar  line  drawn  behind  the  meatus.  '^  ] 

Ninth  exercise.  The  work  of  this  exercise  consists  in 
performing  a  modified  Stacke.  The  meatus  is  first  en- 
larged from  without,  a  funnel-shaped  opening  resulting. 
This  gives  more  room  to  proceed  conveniently  with  the 
Stacke  which  has  been  described  in  the  seventh  exercise. 

The  shaded  lines  in  Fig.  11  (1)  show  the  place  where  the 
chiseling  is  begun.  The  funnel  shape  as  seen  in  Fig.  12  (2) 
then  results  and  the  shaded  lines  here  show  where  the 


s 

u 

0 


/. 


A. 


Jt/T 


a.  Antrum,    b.  Tympanum,     c.  Meatus,    p.  Probe. 

Fig.  11.     Diagram,  looking  Hown  from  above  showing  steps  of  enlarging 

opening  in  the  modified  Stacke. 


Stacke  is  to  be  begun.  Every  stroke  with  the  chisel  must 
be  preceded  by  the  use  of  the  probe.  Fig.  11  (3)  shows 
the  opening  that  results;  this  may  be  further  worked  out 
into  the  complete  opening. 

The  real  Zanfal  operation  consists  in  working  from  with- 
out and  enlarging  the  funnel-shaped  meatus  until  the 
antrum  is  entered,  without  resorting  to  the  method  after 
Stacke.  Fig.  12  (1).  When  the  antrum  is  large  it  will  be 
soon  entered  and  the  bridge  at  the  point  b  in  Fig.  12  (2) 
will  be  left.    Shaded  lines  show  the  procedure  of  chiseling. 


SURGICAL  ANATOMY  OF  THE  TEMPORAL  BONE. 


63 


This  subject  is  not  exhausted,  but  a  few  brief  descriptions 
of  exercises  have  been  given  with  the  hope  that  they  may 


/. 


5. 


i? 


Fig.  13.    Diagnun  from  above  of  Zanfal's  operation. 


be  of  practical  use,  and  that  the  student  may  be  able  to 
use  this  brief  article  as  an  introductory  guide  to  a  work 
so  interesting  that  it  will  call  forth  his  very  best  effort. 


■■Ml 


INDEX. 


0 


Absctiss 

postauricular,  17 

mastoid,  17,  33 

brain,  46 

epi-dural,  46 

extra-dural,  46 
Acute  otitis  media,  26 
Acute  external  otitis,  21 
Acute  mastoiditis,  17,  33 
Acute  suppurative  otitis,  31,  33 
Anemia  of  the  labyrinth,  40 
Atrophy  of  drumhead,  28 
Aspergillus,  21 
Auditory  canal,  external,  49,  20 

diseases  of,  20 

foreign  bodies  in,  19 
Auricle,  17 

Auscultation  (auscultation  tube), 
14,  27,  28,  29 

B 

Bezold's  symptom,  18 
Bulging  of  drumhead,  26,  27 


Canal,  external  auditory,  20,  49 
Catarrhal  otitis  media,  28 
Caries,  36,  37 

Catheter,  eustachian,  14,  27,  28 
Chalky  deposits  in  drumhead,  24 
Chronic    non     suppurative    otitis 

media,  27 
Chronic  catarrhal  otitis  media,  28 
Chronic  suppurative  otitis  media, 

31,  35 
Circumscribed  external  otitis,  21 
Cerumen,  impacted,  20 


Classification 

of  external  ear  diseases,  21 
of  internal  ear  diseases,  40 
of  inti ."^cranial  complications,  45 
of  middl<;  ear  diseases,  25 

Cone  of  lighl,  23 

Congestion  of  drumhead,  24,  26 


Deafness,  15 

Destruction  of  tympanic  membrane, 
25,  29,  37 

Diffuse  external  otitis,  21 

Drumhead,  23 

landmarks  of,  23,  24,  49 
normal  conditions,  2.'^ 
abnormal  conditions,  24 


Eczema  of  auricle,  17 
Effusion,  serous,  in  tympanic  cav- 
ity, 27 
Enlarged  glands,  17 
Epidermal  flakes,  20 
Epidural  abscess,  46 
Examination,  15,  16 
External  auditory  canal,  49 
External  otitis,  21 

circumscribed,  21 

diffuse,  21 
Exostosis,  22 
Extradural  abscess,  46 


Facial  nerve  paralysis,  45 
Fluid  in  tympanic  cavity,  serout, 
27 


(64) 


INDEX. 


65 


Folds,  23 

anterior,  23 

posterior,  23 
Foreign  bodies  in  canal,  19 
Fork  tests,  43 
Furunculosis,  21,  49 
Glands,  enlarged,  16,  17 

a 

Granulations,  30,  35  36,  37 

H 

Haematoma,  17 

Hammer,  30,  30 

Hearing  Tests,  28,  42 

History,  15,  19 

Hyperemia  of  the  labyrinth,  40 

Hyperplasia,  28 

I 

Impacted  cerumen,  20 

Inner  wall  of  tympanic  cavity,  30 

Internal  ear,  46 

Intracranial  complications,  45 


Keratosis  obduruns,  20 

L 

Labyrinth,  inner  wall,  29 
Labyrinthitis,  40 
Landnmrks  of  drumhead,  23,  24 
Light  spot,  23 


Malleus,  30,  36,  23 

Malformations  of  auricle,  17 

Mastoid,  17 

abscess  of,  17 

operation,  sinple,  33,  35,  38 

operation,  radical,  39,  55 


Mastoiditis,  17,  33 
Membrana  tympani,  23,  49 

absence  of,  25,  29,  30 

anterior  fold  of,  23 

bulging  of,  26,  27 

calcareous  deposit,  24 

color  and  lustre,  24 

defect  of,  25 

perforation  of,  25 

posterior  fold  of,  23 
Membrana  tlaccida,  24,  36 
Membrana  vibrans,  24,  36 
Meniere's  disease,  40 
Meningitis,  45,  46 

N 

New  growths  of  auricle,  17 
Non-suppurative  otitis  media,  27 

acute,  26 

chronic,  27 
Noises,  ear  (see  Tinnitus  aurium) 


Operations,  38,  39 

Otitis 

circumscribed  external,  21 
diffuse  external,  21 

Otitis  media 

acute  non-suppurative,  26 
acute  suppurative,  31,  33 
chronic  non-suppurative,  27 
chronic  suppurative,  31,  35 
post  suppurative  conditions, 
29 

Otomycosis,  21 

Otosclerosis,  28 

Ossicles,  30 

Ossiculectomy,  38,  56 

Oval  window,  30 


Paralysis  of  facial  nerve,  45 
Perforation  of  drumhead,  25,  29, 
33,  35,  36 


■ 


66 


INDEX. 


I 

I 

» 

■i 
0 

\J 


Perichondritis,  17 
Perioatitio.  17 
Periotic  n  ,'ion,  17 
Phamyx,  16 
Politier  bag,  14,  27 
Polyp,  18,  36 
Probe,  16,  18,  37,  49 
Process, 

mastoid.  17 

short,  or  malleus,  23 


Radical  operation,  39,  55 
Retraction  of  drumhead,  23,  26, 

Rinne's  test,  43 
Round  window,  30 

S 

Salpyngitis,  eustachian,  26 
Scaas  of  drumhead,  24,  29 
Schrapnell's  membrane,  24,  36 
Serous  fluid  in  tympanic  cavity. 

Short  process  of  hammer,  23 

Sinus 

in  postauricular  region,  18 
sigmoid,  46 
thrombosis  of,  46 


Speculum,  14 

ear,  14 

nose,  14 

met  hod  of  introduction,  16 
Suppurative  otitis  media 

acute,  31,  33 

chronio,  31,  35 
Swelling 

in  external  canal,  22 

over  mastoid  region,  17 
Syphilis  of  internal  ear,  41 


Tenderness  over  mastoid  tip,  17 
Tests,  hearing,  42,  43 
Tinnitus  aurium,  40 
Tip,  mastoid,  17 
Triangular  light  spot,  23 
^™Panic  membrane,  23,  49 
Tympanum,  27 
Tuning  forks,  40 


Umbo,  23 

Vibrissae,  18 
Vertigo,  40 


U 
V 

w 


Wax  (see  cerumen),  18 
Weber's  test,  43     • 


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